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NATIONAL ASSOCIATION 

FOR THE STUDY AND PREVENTION 

OF TUBERCULOSIS 



Y 



National Association 

for the Study and Prevention 

of Tuberculosis 



TRANSACTIONS 

OF THE 

FIRST ANNUAL MEETING 

WASHINGTON, D. C. 

May 1 8th and 19th, 1905 






NEW YORK 

Irving Press, 225 Fourth Ave. 

1906 



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The National Association for the Study 
and Prevention of Tuberculosis 



PRESIDENT 

Dr. HERMANN M. BIGGS 

HONORARY VICE-PRESIDENT 

Dr. WILLIAM OSLER 



VICE-PRESIDENTS 

Dr. LAWRENCE F. FLICK Dr. VINCENT Y. BOWDITCH 

TREASURER 

Gen. GEORGE M. STERNBERG 

SECRETARY 

Dr. henry BARTON JACOBS 
II Mt. Vernon Place, West, Baltimore, Md. 

DIRECTORS 

Dr. Howard S. Anders, Philadelphia Dr. Edward G. Janeway, New York 

Ernest P. Bicknell, Chicago Dr. Arnold C. Klebs, Chicago 

Dr. Hermann M. Biggs, New York Dr. S. A. Knopk, New York 

Dr. Vincent Y. Bowditch, Boston Dr. Charles L. Minor, Asheville 

Dr. Henry M. Bracken, St. Paul Dr. Edward O. Otis, Boston 

Dr. Norman Bridge, Los Angeles Dr. Leonard Pearson, Philadelphia 

Maj. Geo. E. BusHNELL.Fort Bayard, N.M. Henry Phipps, New York 

Dr. William S. Carter, Galveston Dr. William Porter, St. Louis 

Otis H. Chii.ds, Pittsburg Dr. Charles O. Probst, Columbus, O. 

Edward T. Devine, New York Dr. Mazyck P. Ravenel, Philadelphia 

Dr. Lawrence F. Flick, Philadelphia Dr. S. E. Solly, Colorado Springs 

Homer Folks, New York Gen. George M. Sternberg, Washington 

Dr. John P. C. Foster, New Haven Dr. Edward L. Trudeau, Saranac Lake 

Dr. John S. Fulton, Baltimore Dr. Victor C. Vaughan, Ann Arbor 

Frederick L. Hoffman, Newark, N. J. Dr. Joseph Walsh, Philadelphia 

Dr. John N. Hurty, Indianapolis Dr. William H. Welch, Baltimore 

Dr. Henry Barton Jacobs, Baltimore Gen. Walter Wyman, Washington 



LIVINGSTON FARRAND 

Executive Secretary 

United Charities Building, 105 East 22d Street 

NEW YORK 



LOCAL COMMITTEE OF ARRANGEMENTS 

Dr, George M. Kober, Chairman 
Dr. D. Percy Hickling Dr, William C. Woodward 



TABLE OF CONTENTS 



PAGB 



Report of Meeting 9 

Address of the President, by Edward L. Trudeau, M.D 13 

Address of the Vice-President, by William Osier, M.D 20 

Address of the Vice-President, by Hermann M. Biggs, M.D 23 

The Winning Fight, by Talcott Williams 28 

Health as an Investment, by Homer Folks 37 

A Working Program, by Edward T. Devine 51 

The Progress of the Sanatorium Movement in America, by William H. Baldwin. . 70 

Infection in Transportation, by H. M. Bracken, M.D 92 

The Therapeutic Value of Marmorek's Anti-Tubercular Serum, by Arthur J. 

Richer, M.D 127 

The Natural and Artificial Protection of Man Against Tuberculosis, by F. Figari, 

M.D 130 

The Serum Diagnosis of Tuberculosis, by Hugh M. Kinghom, M.D 136 

Studies in Agglutination, by Mazyck P. Ravenel, M.D., and H. R. M. Landis, 

M.D 140 

The Properties of the Serum of Immunized Rabbits, by E. R. Baldwin, M.D,, 

H. M. Kinghom, M. D., and A. H. Allen, M.D 143 

An Histological Study of the Lesions of Immunized Rabbits, by Joseph L. Nichols, 

M.D 149 

Two Experiments in Artificial Immunity Against Tuberculosis, by Edward L. 

Trudeau, M.D 157 

Examination of the Blood in Pulmonary Tuberculosis, with Special Reference to 

Prognosis, by Josephus T. UUom, M.D., and Frank A. Craig, M.D 166 

Tuberculosis of the Thoracic Duct and Acute Miliary Tuberculosis, by Warfield 

T. Longcope, M.D 182 

Vicarious Action of the Bowels for the Kidneys in Tuberculosis, by Lawrence F. 

Flick, M. D., and Joseph Walsh, M.D 198 

Note on the Stability of the Cultural Characters of Tubercle Bacilli, with Special 

Reference to the Production of Capsules, by Theobald Smith, M.D 211 

The Vitality of Tubercle Bacilli in Sputum, by David C. Twichell, M.D 221 

Studies in Mixed Infection in Tuberculosis, by Mazyck P. Ravenel, M.D., and 

J. Willoughby Irwin, M.D 231 

The Thyroid in Tuberculosis, by William B. Stanton, M.D 239 

Landry's Paralysis Complicating Pulmonary Tuberculosis, by D. J. McCarthy, 

M.D 243 



VIU CONTENTS 

PAGE 

Impalpable Sputum, as a Usually Overlooked Danger in Tuberculosis, by Norman 

Bridge, M. D 253 

Report of the Committee on Clinical Nomenclature 259 

Report of the Committee on Early Diagnosis of Tuberculosis 268 

Results of the Open- Air Treatment of Surgical Tuberculosis, by W. S. Halsted, 

M.D 281 

Report of the Committee on the Influence of Climate in Pulmonary Tuberculosis. . 304 
The Influence of the Event of the Tuberculous Upon Native Population, by 

Charles F. Gardiner, M.D 316 

Sanatorium Provision with Industrial Opportunities for Indigent Consumptives, by 

Herbert M. King, M.D., and Henry B. Neagle, M.D 325 

Detention Institutions for Ignorant and Vicious Consumptives, by John P. C. 

Foster, M.D 333 

What Cases are Suitable for Admission to a State Sanatorium for Tuberculosis, 

Especially in New England? By Herbert C. Clapp, M.D 339 

Six Years' Experience at the Massachusetts State Sanatorium for Tuberculosis at 

Rutland, Mass., by Vincent Y. Bowditch, M.D., and Henry B. Dunham, 

M.D 349 

Tent Colonies in Management of Tuberculosis, by J. W. Pettit, M.D 359 

Sanatorium Treatment in an Appropriate Climate, by Major G. E. Bushnell 362 

The Treatment and Care of Advanced Cases of Pulmonary Tuberculosis, by S. A. 

Knopf, M.D 371 

Home Treatment of Tuberculosis, Either in Favorable or Unfavorable Climates,by 

Edward O. Otis, M.D 389 

Report of the Committee on an Educational Leaflet for Distribution Among the 

People 406 

The After Treatment of Pulmonary Tuberculosis, by J. A. Wilder, M.D 413 

Clinical Suggestions From the Study of 500 Cases of Pulmonary Tuberculosis, by 

Henry P. Loomis, M.D 421 

Clinical Studies at Mount St. Rose, by William Porter, M.D 431 

History and Work of the Bedford Sanitarium for Consumptives, by Alfred 

Meyer, M.D 438 



FIRST ANNUAL MEETING 

OF THE 

NATIONAL ASSOCIATION FOR THE STUDY AND 
PREVENTION OF TUBERCULOSIS 



The first annual meeting of the National Association for the 
Study and Prevention of Tuberculosis was held in Washington, D. C, 
May i8 and 19, 1905. The sessions were held at the New Willard 
Hotel, the headquarters of the Association, the local arrangements 
being in the hands of a committee consisting of Dr. George M. Kober, 
Chairman, Dr. D. Percy Hickling and Dr. William C. Woodward. 

In preparing the programme the Executive Committee had pro- 
vided for three sections, a sociological, a clinical and climatological, 
and a pathological and bacteriological. Each of these sections held 
two sessions and in addition there were two general meetings of the 
Association, one on the morning of May 18 and the other on the even- 
ing of the same day. The regular business of the Association was 
transacted on the morning of May 18, following the presidential and 
vice-presidential addresses, and on the evening of the i8th, following 
the public address of Mr. Talcott Williams. The President of the 
Association, Dr. Edward L. Trudeau, presided at both general meetings, 

A summary of the transactions follows : 

On motion of Dr. Lawrence F. Flick, of Philadelphia, it was 
voted that the President appoint a Committee on Resolutions to consist 
of five members, to which all resolutions should be referred be- 
fore being brought before the Association for action. The President 
appointed as members of the Committee on Resolutions, Dr. William 
H. Welch, Chairman, Dr. Edward G. Janeway, Dr. DeLancey Roch- 
ester, Mr. Edward T. Devine, and Dr. H. R. M. Landis. 

The Secretary announced that six directors retired by expiration 
of term of office and that one vacancy existed by resignation. 

The Secretary presented the nominations of the Board of Di- 
rectors for the vacant directorships as follows: 

9 



lO NATIONAL ASSOCIATION FOR THE STUDY 

Dr. William S. Carter, of Galveston, in place of Dr. William 
Osier, resigned. 

For Directors to serve for a term of five years : 

Mr. E. P. Bicknell, of Chicago; 

Dr. Vincent Y. Bowditch, of Boston; 

Dr. John S. Fulton, of Baltimore; 

Dr. Arnold C. Klebs, of Chicago; 

Mr. Henry Phipps, of New York; 

Dr. C. O. Probst, Columbus. 

There being no other nominations, on motion of Dr. DeLancey 
Rochester the Secretary cast a ballot for the names presented, and the 
gentlemen were declared elected. 

The Committee on Resolutions made its report through the Chair- 
man, Dr. William H. Welch, the following resolutions being recom- 
mended for adoption : 

Introduced by Dr. William Osier: 

RESOLVED, That the sincere thanks of The National Association for the 
Study and Prevention of Tuberculosis be tendered to Mr. Henry Phipps for his 
nobk benefaction in connection with the study, prevention and cure of tuber- 
culosis. 

Adopted. 

Introduced by the Board of Directors: 

WHEREAS, Dr. William Osier, one of our founders and a potent factor 
in the development of our organization, has been called to another field of labor, 

RESOLVED, That we express our appreciation of his valuable services; 

RESOLVED, That we elect him an Honorary Vice-President as a mark of 
our appreciation and esteem. 

Adopted. 

Introduced by Dr. George M. Kober: 

The National Association for the Study and Prevention of Tuberculosis 
hails with gratification the establishment and successful operation of National 
Sanatoria for the treatment of tuberculous patients belonging to the Army, the 
Navy and the Marine Hospital and Public Health Service, and trusts that their 
usefulness may be enlarged in every possible manner in the study and prevention 
of tuberculosis. 

RESOLVED, That in the interest of preventive medicine and the cause 
of industrial hygiene this Association respectfully recommends to the Chief 
Executive of the Nation the desirability of instituting an inquiry through the 
proper officers of the Government as to the sanitary conditions existing in all 
Government offices and workshops where a large number of persons are em- 
ployed, especially with a view of recommending, if necessary, measures for the 
prevention of tuberculosis therein. 

Adopted. 



AND PREVENTION OF TUBERCULOSIS II 

Introduced by the Board of Directors: 

RESOLVED, That the attention of all Municipal and State authorities be 
especially directed to the enormous economic importance to every community of 
the Tuberculosis Problem and the wisdom of and the necessity for the provision 
of adequate funds and the enactment of proper regulations for combating the 
prevalence of this disease. 

Adopted. 

Introduced by the Clinical and Climatological Section : 

RESOLVED, That the Officers of the Association be directed to request 
the Directors and Officers of Insurance Associations to unite themselves with 
this Association, and to consider the advisability of giving financial aid to Sana- 
toria for the treatment and prolongation of life of those insured in their com- 
panies. 

RESOLVED, That the Directors and Officers of Insurance Associations 
be invited to attend the next meeting of this Association. 

Adopted. 

Introduced by Mr. E. T. Devine: 

Inasmuch as President Roosevelt in his last message to Congress has em- 
phasized the importance and the possibility of making the National Capital a 
model city in sanitary and social matters, and 

Inasmuch as the President has suggested the formation of a " Special Com- 
mission on Housing and Health Conditions in the National Capital " to be com- 
posed of unpaid prominent citizens of Washington provided with money for 
necessary expenses by congressional appropriation, served by a competent paid 
secretary for the twelve or sixteen months which would be requisite for the work, 
therefore be it 

RESOLVED, That the National Association for the Study and Prevention 
of Tuberculosis earnestly recommends to the Congress of the United States the 
early passage of legislation providing for the appointment of such a commission 
either by the President of the United States or the Commissioners of the District. 

This Resolution met with opposition and was referred back to 
the Board of Directors. 

At a meeting of the Board of Directors held on the evening of 
May 1 8th the following officers were elected for the ensuing year: 

President — Dr. Hermann M. Biggs ; 

1st Vice-President — Dr. Lawrence F. Flick; 

2nd Vice-President — Dr. Vincent Y. Bowditch ; 

Secretary — Dr. Henry Barton Jacobs ; 

Treasurer ■ — General George M. Sternberg. 

In addition to the President and Secretary and the Vice-Presi- 
dents, Mr. E. T. Devine and Doctors Foster, Klebs, Ravenel, Trudeau, 
and Welch were elected members of the Executive Committee. 

The meeting closed with a testimonial banquet to the President, 
Dr. Edward L. Trudeau, on the evening of the 19th. 



12 NAT. ASS'n for STUDY AND PREV. OF TUBERCULOSIS 

Report of the Treasurer 



Receipts : 

Membership dues $1,870.00 

Donations 8,460.00 

Sales, etc 13.60 

Interest 23.55 

$10,367.15 
Expenditures : 

Rent 102.67 

Salaries 1,606.65 

Expenses of New York Office 450^00 

Expenses of Treasurer's Office 13.00 

Handbook and Directory 633.95 

Stationery and Printing 211. 16 

Office Equipment, Books, etc 196.25 

International Central Bureau Memberships. 122.00 

Press Clippings 10.00 

Incidentals 19.28 

3,364.96 

Balance on hand April 30, 1905, $7,002.19 

George M. Sternberg, 
Treasurer. 
Examined and found correct: 
John S. Fulton, M. D., 
Leonard Pearson, M. D., 

Auditing Committee. 



ADDRESS OF THE PRESIDENT 



THE NATIONAL ASSOCIATION FOR THE STUDY 
AND PREVENTION OF TUBERCULOSIS 

By Edward L. Trudeau, M. D. 
Saranac Lake 



This, the first regular meeting of the National Association for 
the Study and Prevention of Tuberculosis, marks an epoch in the 
history of the struggle against the disease in America. It means that 
through knowledge have come responsibility and hope, and through 
both, action. The " great white plague " has ever been so gigantic and 
hopeless a problem that until recent years men have accepted the holo- 
caust of human life which it has ever claimed, and the terrible suffering 
it entails on humanity, as an inevitable decree of fate, and have either 
looked on with Oriental fatalism or turned their heads and passed by 
on the other side with a hopelessness born of despair and of ignorance 
as to the etiology of the disease. 

For many years the pathologist labored faithfully and unremit- 
tingly, but unsuccessfully, to solve the problem of tuberculosis; but 
by the application of the experimental method, and with the birth of 
the new science of bacteriology, Vielmin, Koch, Cornet, and others, 
threw a light on the etiology of tuberculosis which, little by little, has 
inspired men with new hope and led them to the conviction that since 
tuberculosis is a communicable disease and its etiological factor has 
been discovered, it is also to a great extent a preventable one. 

The realization of this truth, so vital to mankind, has come but 
slowly, and for the past twenty years workers in this field have 
struggled long and patiently to demonstrate the validity of this new 
hope, and to accumulate indubitable evidence as to the practical efficacy 
of preventive measures, while others, by improved methods of diag- 
nosis and treatment, have demonstrated the possibihty of a much earlier 

13 



14 NATIONAL ASSOCIATION FOR THE STUDY 

detection of the disease, and its curability when treated by the open-air 
method. 

I congratulate those of you who have so many years been engaged 
in this arduous task that your labors have not been in vain, and that at 
last tuberculosis is recognized generally as communicable, preventable, 
and, in its earlier stages and rnoje fa vocable types, curable. 

To this demonstration, the National Association for the Study and 
Prevention of Tuberculosis owes its existence, and its moving force 
to-day is the hopefulness based on facts garnered in this field by in- 
dividual workers during the past twenty years. This newly gained 
knowledge needs but to be applied in order to insure success, and it 
has long been evident that the efforts of the individual workers can be 
of little avail in meeting so vast a problem — one which ten years ago 
would have been thought beyond the power of man — namely, the re- 
duction of the death-rate from tuberculosis over all the United States 
of America. To accomplish this the National Association should be 
something more than a medical society devoted to the study of tuber- 
culosis. Its watchwords should be organization and co-operation ; an 
organization so perfect and a co-operation so broad that, through edu- 
cation, it will bind together for the attainment of a common aim the 
laity, the profession, the state, and the nation. 

Abroad the value of organization and co-operation has already 
been recognized, and the modern crusade against tuberculosis finds 
European nations not as units, each following its own independent 
path, but banded together in an international association, with a cen- 
tral bureau in Berlin, issuing its monthly publications in three lan- 
guages, and bringing together at its meetings held at stated intervals 
the best minds of medical and related professions of all countries for 
deliberation and consultation. 

Tardily though it be, with us a beginning has been made. The 
United States is no longer without representation among the nations 
in their combined struggle with the great white plague, and this asso- 
ciation is now part of that vast international movement to stamp out 
tuberculosis which has been steadily spreading over the world. Organi- 
zation and co-operation are the key-notes of the age, and the two main 
factors on which the success of the vast undertaking of modern times 
has depended. On their thorough application and broadest interpre- 
tation depends the degree of success the National Association will 
achieve. The first problem before it is to combine and direct the 



AND PREVENTION OF TUBERCULOSIS 1$ 

scattered efforts of individual workers and existing associations, and 
to extend and expand the field of these efforts. The precise lines along 
which the great society will develop its work rests with you and 
the future. 

One of the first steps to be initiated would seem the adoption 
of a plan of organization that would bring each state, by means 
of one or more representatives, lay and professional, in touch with the 
National Association. To these representatives would be delegated the 
carrying out of the anti-tuberculosis crusade in their respective states 
along the lines recommended by the National Association, making at 
the annual meeting their report of the progress accomplished. Through 
a publication of its own the National Association should keep its mem- 
bers in touch with one another's work and methods, and with any 
advances made in meeting the sociological problems which stand in 
so important a relation to tuberculosis, as well as in perfecting its muni- 
cipal control and advancing its study and methods of treatment. 

The first and greatest need is education ; education of the people, 
and through them education of the state. It is evident that if every 
man and woman in the United States were familiar with the main facts 
relating to the manner in which tuberculosis is communicated and the 
simple measures necessary for their protection, not only might we 
reasonably expect as a direct result of this knowledge a great diminu- 
tion in the death-rate of the disease, but the people would soon demand 
and easily obtain effective legislation for its prevention and control. 

When a state has once become well educated, and not before, will 
the other requisites necessary to the control of the disease be forth- 
coming. These requisites are briefly, a higher standard of public 
hygiene and improved conditions of life for the masses ; sanitary laws 
embodying the municipal control of tuberculosis as it is now under- 
stood; the segregation of the tuberculous in public institutions and 
prisons ; the establishment of sanatoriums for incipient cases ; hospitals 
for advanced and hopeless ones who cannot be cared for safely at their 
homes ; especially organized dispensaries, laboratories for research, etc. 

Education should begin by teaching in the public schools the main 
facts relating to the transmission of tuberculosis, insisting in such 
teachings on the value of hygienic measures of prevention, and dwelling 
as little as possible on the details of the bacteriology of the disease, 
which would tend to produce in imaginative young minds exaggerated 
and fantastic impressions of the dangers of infection ; education of the 



1 6 NATIONAL ASSOCIATION FOR THE STUDY 

masses by distribution of suitable literature, by lectures to trades unions 
and various organized bodies, by free museums, tuberculosis exhibi- 
tions, and through the medium of the public press and periodical litera- 
ture. Education, by teaching just where the danger lies and the simple 
measures necessary to avoid it will tend to quiet and control the un- 
reasoning and ignorant terror of infection which often works such 
hardship and injustice to the consumptive. Early detection of the dis- 
ease is the first requisite for success in its treatment, and it is through 
education alone that incipient cases will be induced to seek advice early 
and to make at the right time the sacrifices necessary to bring about 
their recovery. 

Education will help to crush the vampire of quackery which preys 
ever on the misfortunes and ignorance of the poor consumptive, appeal- 
ing with devilish ingenuity, through specious advertisements of myste- 
rious specifics and cures, to his credulity and hope, masquerading under 
the guise of science and even of philanthropy, in order to wring from 
him his small savings, and then casting him off, when these have been 
exhausted and his disease is well advanced, doomed to a lingering death, 
helpless, hopeless, and a heavy burden on the overtaxed resources of 
a charitable community. May the time soon come when the National 
Association will be in a position to put its heel on the demon of quack- 
ery, not only by educating its victims but by applying its large resources 
and influence to bring the offenders to justice. 

Educational measures should not be confined to the public, but, 
along different lines, extended to the profession as well. Medical 
schools should be urged to give special didactic and clinical instruction 
in advanced methods of making an early diagnosis. In graduating 
from most medical schools the young practicioner is too apt to carry 
with him the picture of tuberculosis as he has seen it in the advanced 
cases usually shown at clinics and dispensaries. Incipient tuberculosis 
he has not been taught to recognize. On the general practitioner and 
the dispensary physician rests the great responsibility of detecting the 
disease in its incipiency, for it is to them and not to the specialist that 
the patient first applies. Not by lectures alone, but by clinical instruc- 
tion as well, should medical students be taught how to detect the varied 
and insidious onset of incipient tuberculosis, impressing on them the 
curability of the disease in its earlier stages, and for this reason the 
responsibility of making a diagnosis before the classical symptoms of 
pulmonary consumption develop. The various sanatoriums offer such 



AND PREVENTION OF TUBERCULOSIS 1 7 

rich opportunities for clinical instruction in incipient tuberculosis, early 
diagnosis, and treatment, that summer courses could with great advan- 
tage be given at these institutions. 

The value of the tuberculin test when applied to cases where a 
positive diagnosis cannot be made by ordinary methods has not yet been 
fully recognized, and in my experience its unreliability and dangers 
have been much exaggerated. A method which enables the physician 
to reach a positive conclusion as to the presence or absence of tuber- 
culosis long before it can be done by ordinary clinical methods is of 
such vital importance in all attempts at curing the disease that it is to 
be hoped the National Association will be a medium through which a 
more exact knowledge of its scope, its limitations, and its real value 
may be reached. 

The practical application of knowledge already gained as to the 
measures briefly touched upon, and which represent prevention, is one 
of the two great responsibilities of the National Association. The other 
is the extension and advancement of the study of tuberculosis in this 
country. The United States, at any rate so far as tuberculosis is con- 
cerned, should not much longer justly lie under the imputation of being 
" one of the largest borrowers in the scientific markets of the world." 
Already everything points to an awakening to the need and possibilities 
of original research in this country. Within the past five years the 
Carnegie Institute, the Rockefeller Institute^ and the Phipps Institute, 
have been founded and generously endowed. Many laboratories have 
been opened in connection with colleges and hospitals, and journals 
and societies devoted to original research have sprung into life, so 
that before many years American science will have won its place in the 
world's scientific advances in the field of medical research. The 
scientific study of tuberculosis, however, offers so broad a field, and 
one requiring observations extending over such long periods of time, 
that special permanent endowments solely for researches in tubercu- 
losis, which would enable experimentation in this field to be carried 
on continuously through a number of years, are greatly needed. 

In time the san.atoria can furnish, from carefully kept records 
extending over many years, valuable data hitherto unattainable, bear- 
ing on the history, varied clinical manifestations and treatment of the 
disease, and improvement in methods of municipal control will speedily 
develop along the lines already so wisely instituted. 

But it is mainly to the laboratory research work that we must 



l8 NATIONAL ASSOCIATION FOR THE STUDY 

look for the solution of many of the as yet unsolved problems of 
tuberculosis, and for advance in our methods of prevention and treat- 
ment. The study of different sources of infection ; of the great varia- 
tions of virulence in tubercle bacilli and how brought about; of the 
different species of the tubercle bacillus and of related bacteria ; their 
relation to each other and to the disease ; the chemistry of their toxins ; 
and, above all, the mechanism of natural immunity and the possibility 
of producing artificial immunity to the germ or to its toxins; the 
mechanism of such an artificially induced resistance — are but a few of 
the subjects of the utmost interest at present, on which the laboratory 
alone can throw much-needed light. 

Although artificial immunization against tuberculosis has hith- 
erto been looked upon as a dream never likely to be realized, during 
the past ten years a great deal has been added to any knowledge of 
mechanism of natural and acquired immunity against infectious dis- 
eases, and appreciable advances have been made in producing in 
animals a relative degree of artificial immunity against tuberculosis. 
If further researches are ever to result in some safe method of inocu- 
lation that will produce artificial immunity, or even greatly increased 
resistance to tuberculous infection, it is to the laboratory that we must 
look for such an achievement. 

Along these lines, laid down by its founders, and which I have 
briefly touched upon, the National Association for the Study and 
Prevention of Tuberculosis bids fair to work out its destiny. 

On the spirit of a work like this depends its life and success. 
The motive which has brought you together, and the spirit which has 
made possible the existence of the National Association, is to my mind 
the best guarantee of its success; for its work represents the highest 
type of unselfish human endeavor and the highest aim of a noble pro- 
fession; namely, the struggle for the existence of others — a struggle 
which will not be rewarded even by the gratitude of those whose lives 
you will save, for they will never even know that they have been saved. 

If the National Association succeeds in co-ordinating and bind- 
ing together in one sustained and well-directed effort the scattered 
energies which have sprung into life all over this great country, if 
it can secure the co-operation of the sociologist, the legislator and the 
philanthropist, if its organization is complete and its members have 
become imbued with the greater meaning and true spirit of co-opera- 
tion, a co-operation ever ready to sacrifice selfish aims to the success 



AND PREVENTION OF TUBERCULOSIS IQ 

of a great cause — a co-operation which to the athlete means team- 
work, and to the soldier discipline — it cannot but prove a powerful 
instrument in the struggle against tuberculosis in this country. 

It has been said : " The degree of civilization of a people will in 
time be indicated by the figures of its death-rate." If this be so the 
National Association has indeed a great responsibility, one which it 
nevertheless seems well fitted to assume. 



ADDRESS OF THE VICE-PRESIDENT* 

By William Osler, M. D. 
Oxford 



Our Chairman has touched upon the one important point in this 
great movement, namely education. There are two aspects to the edu- 
cational problem; (i) the getting of knowledge, which is not, after 
all, a very difficult thing to do. The question is whether, under some 
circumstances, we have not a little too much knowledge. We perhaps 
are sometimes embarrassed by the knowledge we have. The knowl- 
edge which we have of tuberculosis is really enormous. When you 
think what an influence the last century has had on this subject of 
knowledge, it is one of the most remarkable of human achievements. 
The second aspect is the difficult problem: making this knowledge 
effective; getting sense and getting wisdom; these are totally separate 
and distinct. Never was a more appropriate word said than that by 
Tennyson, " Knowledge comes but wisdom lingers." There are three 
to educate, the public, the profession and the patient. The public 
is awake; sitting on the edge of the bed not yet dressed, but still it is 
an improvement even to get the public awake. With this awakening 
the rest is pretty sure to follow. The public has three great duties 
in this problem ; first, the enactment of good laws, and it is nice to be 
able to say New York laws. In spite of its frivolity, its size and its — 
other things to which I hesitate to allude, New York has set the pace 
for the other cities. 

The second public duty is the proper care of the early tuberculous 
case ; whether it be by public or private munificence does not make any 
difference. This is the second important public duty. 

The third is the care of the hopeless case, as the early case is 
not, after all, quite so important for the public as the hopeless case. 
The case in the latter stages is the case from which the disease is often 
spread. 

* Stenographer's Notes. 



NAT. ASS N FOR STUDY AND PREV. OF TUBERCULOSIS 2 1 

The education of the profession is as difficult as the education 
of the public, as we are members of the public. We have their 
peculiarities to a marked degree and their failings in a minor intensity. 
The early recognition is the first and most important duty. This is 
by no means easy, as we are not yet fully educated up to the point 
of dealing with it. " Open confession is good for the soul " ; we might 
just as well confess this; the profession does not always recognize 
these early cases. We have the knowledge but not the recognition, which 
practically determines all the efficiency of the open-air treatment, and 
this is not always recognized by the profession. The other important 
point is the education of the medical students on this question of early 
diagnosis. It is becoming an increasingly difficult thing in the medical 
schools to deal with the whole question of infectious disease. You 
offer to build a hospital for infectious disease in the city and the very 
people most interested, the public, are the very ones who will rise 
up and cry, " Away with it ; it is a damage to our community." It is 
getting more and more difficult to properly educate the medical stu- 
dents, as the general hospitals will not take tuberculosis, although 
in my opinion they should always take a group of acute tuberculous 
infections and a few cases of acute miliary tuberculosis. The next 
most important point is that every general hospital should, for the sake 
of the students, take in several cases of early tuberculosis, just to show 
the students, doctors and nurses what can be done with early cases. 
We very often get excellent results in these cases, and it would be 
a lesson not only to the physician and to the medical students, but most 
important of all, a lesson to the nurses. There is a very definite 
function for the general hospital in this connection. The second im- 
portant function of the general hospital is a tuberculosis dispensary; 
every large general hospital should have, in connection with its dis- 
pensary, a tuberculosis department. This can very easily be established 
and the advantages are enormous. In addition to the educational ad- 
vantages to the students, it is a very great advantage in being a place 
where physicians can send their cases for early diagnosis, as it can be 
done so much better here than in connection with the Board of Health. 
These educational aspects should be borne in mind, and tuberculosis 
cases should be encouraged to come and nurses encouraged to look 
after them. This matter would be a help to the Hospital and to all 
connected with it. 

Lastly, the education of the patient, and here comes our most 



22 NAT. ASS'N FOR STUDY AND PREV. OF TUBERCULOSIS 

trying and difficult task. In the first place you have the friends, who 
will say, " Don't tell that girl she has tuberculosis ; it will kill her ; she 
will die." How often do we hear this! There is no greater mistake 
than to keep from the patient the knowledge that she has tuberculosis 
in its early stages, as it is only by having that knowledge that she can 
be expected to recover. We are criminal participants with the friends 
if we refuse to tell the patient exactly the nature of the trouble. I 
think these are the three most important points in connection with the 
question of education and tuberculosis; the education of the public, 
the profession and the patients. We are all deeply interested in these 
problems ; no one of them is of more interest to us than the other. 

The National Association should stimulate and support work 
along these lines; it will do the public good and the profession good. 
I hope the good work that has been begun so favorably may continue. 

I cannot sit down without bearing testimony to the work of one 
man in this country in connection with this disease ; his work has been 
an inspiration to us all; it has been characterized by courage under 
circumstances that few of you can appreciate and that few of us could 
have overcome; it has been characterized by the boundless enthusiasm 
of a true scientific student. I do not know that there is any one thing 
in his career that impresses me more than that he should have kept 
alight the fires of enthusiasm in the way he has. He has had that care 
of his patient which has characterized him above all other things. 
Lastly, Dr. Trudeau has the true humility of a great man. 



ADDRESS OF THE VICE-PRESIDENT* 

By Hermann M. Biggs, M, D. 
New York 



I HOPE you will pardon me if, instead of addressing my general 
remarks on the purpose of this organization, I shall speak to you 
briefly on a somewhat technical side of the subject. I wish first to say 
a word as to the difficulty experienced everywhere in obtaining sites 
for infectious disease hospitals. I think I can show how erroneous 
is the popular idea as to the dangers connected with them. In New 
York we have a group of hospital pavilions for infectious diseases 
situated on North Brother Island. During the last three years we 
have been treating there, on an area consisting of about eight acres, 
cases of diphtheria, scarlet fever, measles, whooping-cough, chicken- 
pox and tuberculosis in separate pavilions in close association with each 
other. The pavilions for tubercular cases are not more than forty 
feet from those occupied by the scarlet fever and diphtheria patients, 
and there is very little restriction in the movements of cases in the 
open air outside the pavilions. The tuberculous patients are allowed 
to roam over the Island, with few restrictions. This has been the situa- 
tion for three years, there being at the present time about eighty cases 
of tuberculosis on the Island. There has never been a single instance 
in which scarlet fever, diphtheria, or any other contagious disease has 
been transmitted to one of these tubercular patients, or the reverse. 
Whenever the question of the establishment of a hospital for infec- 
tious disease comes up for consideration near or in any town or city 
there is raised immediately a public outcry against the location of the 
institution anywhere, or at least in any suitable place, and injunctions 
from the Court are obtained to prevent the opening of the institution 
because of the danger to the surrounding inhabitants, and the conse- 
quent influence this is supposed to have in the depreciation of the 
value of the neighboring property. This attitude exists equally to 

* Stenographer's Notes. 

23 



24 NATIONAL ASSOCIATION FOR THE STUDY 

hospitals for tuberculosis as well as those for scarlet fever, diph- 
theria or smallpox, and is so totally unreasonable and is such a 
menace to the public health that it seems to me we should make a 
formal and public protest against it. 

In New York the reception hospital for contagious diseases, 
where cases of smallpox and all other forms of contagious disease, 
as well as tuberculosis, are received, is within four hundred feet of 
one of the most densely populated portions of the city, or of the whole 
world for that matter. In some areas near this institution there are 
one thousand inhabitants to the acre. This hospital has been located 
in the present situation for a number of years and there is not the 
slightest evidence to show that it has ever been the least source of 
danger to the closely adjoining inhabitants of a densely populated 
region. There has never been any evidence that a single case of any 
infectious or contagious disease has resulted from the establishment 
of the institution in this situation. This difficulty in obtaining sites 
for infection disease hospitals is coming up so constantly and the 
popular misconception regarding the subject is so great, that it com- 
prises one of the chief obstacles to the work of preventive medicine. 

As to the enforced registration of tuberculosis, I believe there 
is now no difference of opinion among sanitary authorities as to the 
importance of some form of registration as a necessary preliminary 
to any scheme for the successful administrative control of this disease. 
And yet when we look over the history of this movement we are sur- 
prised to find that enforced registration practically does not exist 
anywhere in this country or abroad except in New York City, with 
the exception of one or two of the smaller cities in this country and 
Great Britain. Regulations requiring the reporting of cases have 
been enacted in many cities, but in almost all of these no further 
action has followed and no steps have been taken to enforce them. 
I do not wish to counsel radical action in this matter, for as Dr. Tru- 
deau and Dr. Osier have so well said, — the whole problem is really 
a matter of education. We must educate the public and the profes- 
sion. The enthusiasm of the younger men, resulting in the adoption 
of radical measures, may do more harm to the cause than the opposi- 
tion, but it is necessary that some measures be taken. In New York 
the Health Department has found that a Medical Advisory Board 
has been of great service in educating the public and inspiring it with 
confidence in the action of the Department. This Board is comprised 



AND PREVENTION OF TUBERCULOSIS 2$ 

of some of the most eminent physicians in New York and is a great 
help to the Department in the carrying out of all new sanitary proce- 
dures. When the medical profession and the public realize that what- 
ever action is taken by the Health Board has been approved by the 
Advisory Board, they at once have confidence in the action of the 
Department far beyond what any other course could have produced. 
The sanitary authorities in other cities would do wisely if they en- 
listed the earnest co-operation of the leading men in the medical pro- 
fession. As to registration in New York, the Board of Health in 
1892 adopted a resolution requiring public institutions and requesting 
private physicians to report all cases of tuberculosis. Every effort 
was made to enforce this resolution and more than 4,000 cases were 
reported the first year. Arrangements for free bacteriological exam- 
inations of sputum were then provided for two reasons, (i) to facil- 
itate the early diagnosis of the disease among the poor, and (2) to 
give a return to the physician for his trouble in reporting the case. 
This second provision has been of very great service. During the 
first year there were 500 specimens of sputum sent for examination, 
whereas last year there were over 17,000. At the rate we have been 
making examinations this year there will probably be over 20,000 
examinations made this year. This plan has been of the greatest 
service in enlisting the co-operation of the medical profession. The 
facilities for these examinations are of the best and there are over 
250 depots scattered throughout the city where the specimens may 
be left for collection by the Department. 

After the resolution referred to had been enforced for three 
years, we felt that the profession and public had become sufficiently 
educated so that we were justified in requiring the reporting of all 
cases, and an amendment to the Sanitary Code was then adopted to 
this effect. The Department declared tuberculosis to be a commu- 
nicable disease — not a contagious disease in the ordinary sense. The 
other diseases known as contagious differ very much from it in com- 
municability. This is important, for if we are to allow the impression 
to go abroad that tuberculosis is like smallpox we will encounter the 
greatest opposition and the most serious obstacles. We believe that 
tuberculosis is an infectious disease, only communicable when simple 
sanitary requirements are neglected and when there is constant and 
continuous exposure. Association with a consumptive may be abso- 
lutely free of danger if only simple precautions are taken. If we only 



26 NATIONAL ASSOCIATION FOR THE STUDY 

distinctly separate tuberculosis in our classification from scarlet fever, 
smallpox and such diseases, and if we only clearly define the dif- 
ference, this unreasoning fear of consumption should soon be re- 
moved. We have tried in New York to emphasize the fact that tuber- 
culosis is a communicable disease, not a contagious disease, and that 
it may be rendered free of danger to others if only simple precautions 
are taken. In New York continuous pressure has been brought to 
enforce the reporting of cases. We did not enforce it in the begin- 
ning, but constantly called the attention of the profession to the res- 
olutions of the Board. At first we found a large number of phy- 
sicians who hesitated to send specimens of sputum for examination, 
but later did so willingly. 

Gradually the opposition which existed in the early days has 
been removed and there is now really no serious objection on the part 
of the medical profession to the enforcement of the regulations in 
regard to the care of these cases. The difficulties we meet are less 
in the sanitary supervision of tuberculosis than in that of scarlet fever 
or diphtheria. The education of the public as to what the sanitary 
authorities wish to do is all that is necessary. 

Over 19,000 cases of tuberculosis were reported last year in New 
York and over 7,000 during the first four months of this year. Of 
course these do not all represent new cases. As the cases become 
more and more fully reported there are more and more duplicates, 
and probably this year there will be 6,000 duplicates. As a rule 
probably the patient lives i^ or two years in a tenement house after 
the case has been reported. 

There are certain procedures which we have adopted in reference 
to visitations by trained nurses, etc., but the crucial point of this work 
was in the establishment and formulation of the scheme of registra- 
tion and its enforcement. The enforcement must come only after the 
education of the people and the profession, and when this has been 
accomplished little difficulty will be experienced. Without registra- 
tion any systematic scheme of prevention is impossible. 

In connection with the giving of proper instructions, the edu- 
cational value of registration itself cannot be overestimated. Reg- 
istration does not involve publicity, which is an objection so often 
brought forward. The registration of cases under the care of private 
physicians does not involve any action on the part of the Department 
further than the communication by the Department with the physi- 



AND PREVENTION OF TUBERCULOSIS 27 

cian asking that he see that the proper instructions are given. No 
action is taken in private cases so long as the case remains under the 
care of the physician, but when the case passes from his supervision 
or changes residence then he is required to notify the Department. 
Then the apartment occupied may be properly disinfected. As I have 
said, registration does not involve publicity, and when this is under- 
stood, the objections which are urged against it will be almost en- 
tirely removed. 

The National Association has every reason for congratulation 
at this, its opening session. It has bright prospects and a great field 
of usefulness. We could have no better omen of success than that 
at this first meeting our Presiding Officer should be one to whom 
Dr. Osier has given such a fitting tribute. Dr. Trudeau. 



THE WINNING FIGHT 

Address by Talcott Williams 

Philadelphia 



Besides the patient and the physician, pubHc health and preventive 
medicine, there is a third factor — the duty and relation of the indi- 
vidual towards the struggle with this disease. As the public conscience 
is educated, the individual conscience is quickened. As medical knowl- 
edge grows more complete, personal responsibility grows more im- 
mediate. 

In the past forty years society has changed its attitude towards 
disease, by substituting skilled care for amateur nursing, definite 
knowledge for vague apprehension and systematic prevention for the 
acceptance of disease as a providential necessity. 

Consciously and unconsciously society has been for two centuries 
restricting the spread of transmissible disease. I prefer this term to 
contagious, infectious or epidemic. It raises no issues and defines no 
conditions. Some transmissible diseases like plague and leprosy have 
disappeared under the improvement in the level of life. When men 
and women came to be shod instead of going barefoot, this change 
alone greatly reduced the transmission of plague. The unconscious 
efforts of society had gradually excluded plague from Europe before 
any conscious systematic effort began. If it has appeared in our 
Californian cities, it has been in a population whose standard of life 
has sunk to the plague level. As every student of medical history 
knows, a wide range of transmissible maladies has shrunk as civiliza- 
tion extended. Perhaps half or a third of the shrinkage in the general 
average annual death-rate from 40 per 1000 to 20, in two centuries, 
has been due to this disappearance without conscious effort of trans- 
missible diseases, whose existence is only possible under a low standard 
of life and which disappear as the standard rises. 

The conscious struggle of society with transmissible disease might 

28 



NAT. ASS'N for study AND PREV. OF TUBERCULOSIS 29 

almost be said to have begun a century ago with vaccination. This 
effort to eliminate transmissible disease has for a hundred years fol- 
lowed a singularly logical course. It began with a group of eruptive 
skin diseases in which smallpox led. Vaccination and isolation have 
practically driven smallpox not only out of society but out of sight. 
Where half the population was once marked, many physicians have 
never seen a case. If I have been more fortunate, it is because the East 
of my childhood has not yet begun the struggle with transmissible 
disease. If no prophylaxis like vaccination exists for measles and 
scarlet fever, it is still true that they would disappear if isolation were 
complete. Incomplete as it is, public education is advancing. If the 
curve of the decreasing death-rate and diminishing cases of these 
diseases be carried out, their disappearance is certain before the end 
of the present century. No one could have been as hopeful about 
smallpox a century ago. 

From these eruptive diseases whose contagion and visible cuta- 
neous characters rendered them singularly favorable electives for the 
education of the public, society has gone on to the exclusion of trans- 
missible diseases first from the intestines and next from the thoracic 
cavity in typhoid and tuberculosis. The public awakened to the pos- 
sibility of excluding the poison of typhoid from the intestines somewhat 
earlier than the practicability of excluding contagion from the lungs. 

But properly considered, these are part of the same movement 
which began with the skin and went on to the two greater cavities of 
the body, endeavoring to rid each of its most frequent infection from 
transmissible disease. We are all aware how successful this effort 
has been already. There are many great cities in which there are not 
enough cases of smallpox for a medical student to see one in a four 
years' course. There are cities, though fewer, which have to import 
their cases of typhoid for medical education. Carry out the curve 
of the decrease of tuberculosis, and one may unhesitatingly say that 
the child is now born who will live to see the year in which a well- 
sprinkled, well-swept, well-watched, and well-sanatoriumed city will 
put as many difficulties in the way of the frequent local study of tuber- 
culosis as now exist for the local study of smallpox or typhoid. How 
rare is leprosy? Who here has seen plague? How few have treated 
a case of typhus? 

The fight with tuberculosis which has brought us together is no 
mere isolated accidental attack on a malady which the discovery of 



30 NATIONAL ASSOCIATION FOR THE STUDY 

Koch's bacillus has brought within the range of diseases more readily 
suppressed because their concomitant or cause is known, but part of 
a broad social development following a known and visible succession, 
attacking in regular order transmissible disease and first eliminating 
those which disappear with a rise in the standard of life. Attacking 
diseases peripherally apparent passing on to the protection of the in- 
testines and then of the lungs and certain to go on to another group of 
diseases which I need not here name, but already looming on the hori- 
zon of conscious social prevention. 

Our own attack considered merely as an assault on a malady which 
causes nearly a tenth of the total mortality and a third of the adult 
deaths in the period of greatest vigor might seem hopeless; but re- 
garded as part of a systematic and ordered though unconscious move- 
ment of society which has attacked one field of transmissible disease 
after another, our crusade becomes not merely full of hope, but 
crowned with certainty in a future far nearer than most appreciate who 
have not asked themselves where the fast reduction of the death-rate 
from these diseases in a century would bring us if continued as a 
developing curve. It is already clear that transmissible disease is to 
be steadily transferred from private practice to the general care of the 
public health. For smallpox this has now come. It is next to never 
treated save from the standpoint of public health. Typhoid is travel- 
ling the same road. So is tuberculosis. The day is already near when 
it will be seen that the entire field of transmissible disease belongs to 
the state and the state alone, prevention, prophylaxis and cure. 

Instantly to every physician will occur the converging facts which 
indicate the recognition of the fact that transmissible disease must be 
treated from its public aspect and not from the individual case. When 
the public conscience fully educated will stimulate individual responsi- 
bility, the duty of the state is the duty of the citizen. There was 
a time when smallpox was the practising physician's daily charge. 
The path this has gone, other transmissible diseases will travel. How 
near is the time when, transmissible disease having become the exclu- 
sive care of public medicine in its various fields, official and unofficial, 
the practising physician will in his private practise be attending only 
three broad classes, traumatic lesions, functional disorders, and the 
redress of deficiencies due to lack in the growth of the infant, the strain 
of middle life, or the ebb of old age. 

Our generation has attacked transmissible disease in the two 



AND PREVENTION OF TUBERCULOSIS 3 1 

fields, intestinal and respiratory. The next generation will protect 
other organs. If we are less clear as to the attack on tuberculosis than 
as to the way to reach typhoid and infantile maladies more fatal than 
typhoid it is because society at present can more easily secure the 
purity of the fluids that enter the digestive tract than of the air that 
enters the lungs. It is easier for any of us to make our food healthful 
than our houses. The public is far better educated as to the need of 
pure water and pure milk than as to the need of removing the condi- 
tions out of which tuberculosis comes, whether as cause or concomi- 
tant no one yet can be certain. Here again there has been a logical 
advance, the infection of smallpox is more local and immediate than 
that of typhoid and the control of transmission through water and 
milk is an easier task, dealing with fluids, than the aerial transmission 
of the germ of phthisis, flourishing only, it must be remembered, when 
it finds a congenial soil in a subject already enfeebled. 

There are diseases of which we yet feel in despair (cancer is one 
of them) that the advance of civilization but multiplies their presence. 
Two diseases more clearly transmissible are in the same category. 
But when, as in this country, the average per capita consumption of 
wheat suddenly rises as in the past five years by a full fourth, when by 
another advance meat cattle are substituted for swine in the national 
meat ration, when the growth of the boot and shoe industry doubles 
and a still more rapid increase in the consumption of rubber shows 
that people are yearly better shod and when houses and rooms grow 
faster than human beings, enlarging the average area and air of each 
family, while drainage is in progress on a great scale, we may feel 
certain that the rise in the standard of life is itself reducing this dis- 
ease. Nothing is more necessary than to diffuse this consciousness 
of improvement, to fill the public mind with the conception that the 
fight is half won, that without multiplying figures, the disease has 
been driven from one-half the area of human life on which it battened. 
We are not dealing with a rising flood threatening to overwhelm us. 
We are proposing to dike an ebbing tide and repel a retreating invader. 

For complete victory, public education is more necessary at the 
present time than mere public medicine; though, if we were wise, we 
would see that public education is the larger half of public medicine. 
The contracted thoracic cavity and inert lung is, as we all know, the 
seed-bed of the disease. At birth, there are physically no classes. 
The average capacity of the lung starts the same for all children. 



32 NATIONAL ASSOCIATION FOR THE STUDY 

Speaking as a layman, what needs to be ground into the public mind 
is that this disease is sown by the neglects of society. Individual 
responsibility needs to be emphasized and quickened. Responsibility 
for dust against which woman began the constant and unsparing 
fight far earlier than man. If even 25 years ago we were jesting over 
the feminine frenzy over dust, this masculine pleasantry has perished 
in the knowledge that dust is disease. Sweeping without sprinkling 
in street, yard, railroad-car, depot, parlor, hall, school, and home, 
needs to be penalized as a crime. Not infrequently it could be proved, 
if all were known, to be manslaughter in one of those degrees which 
regards as crime the careless taking of human life. 

Individual responsibility as to employees needs next to be made 
vivid and visible. The English barrack, once the chosen home of tuber- 
culosis in all its forms — is an eloquent proof of what can be done. 
Perhaps one of the deadliest public places in this country is one where 
the flower of my profession each December gathers for its yearly task 
— the press galleries of the Senate and House. Every physician in 
Washington must know, as from my experience I know, that the pro- 
portion of cases of phthisis among hardworking correspondents here 
is large, far larger, I can certify, than under normal and healthy office 
conditions in a home office where a like group is at work. 

No audience ever gathers but there is more than one present un- 
consciously aiding death by the neglect of employees. Our domestic 
servants are wretchedly housed. The prevalence of the disease among 
them is the deadly sin of the American housekeeper and in most houses 
could be cured by care and patient attention to working conditions. 
Why force a cook heated at the fire to go into the yard to open the 
yard back gate, when an electric push and catch will save this ex- 
posure. 

The factory has greatly improved. The home has not kept pace. 
Lastly, at this point, there is the inculcation of perpetual personal pro- 
test against the presence of dust in any public or semi-public place. 
Always kick ! This is the motto which should be written on the heart 
of every American over the daily abuses of public patience at public 
peril to health. 

Food, I need not say, is another point where public vigilance is 
necessary ; but this technical task I leave to the expert. Public opinion 
is needed here, but personal vigilance in the nature of things can do 
little to exclude tubercle, the germ of scarlet or typhoid fever or other 



AND PREVENTION OF TUBERCULOSIS 33 

transmissible maladies from the supply of milk or meat or vegetables. 
This is a task for technical supervision and the rigorous use of the 
police power on a drastic scale. 

It is more germane to a layman's responsibilities that almost un- 
consciously we have reached a point in the ebb of this disease where 
the overwhelming majority of cases is in the over-strained, the strug- 
gling, or the submerged fraction of society. If phthisis has not wholly 
disappeared from the advantaged station of society, it is disappearing. 
Novelists no longer kill off their heroines with consumption. They 
die of heart disease, typhoid, or have nervous prostration, though the 
etiology of fiction is vague in its nomenclature. The vast mass of 
cases in a retreating disease is in the share of the population close to 
the edge of subsistence. Many cases never would occur but for a lack 
of adequate nutrition. Immigrants furnish a disproportionate share 
because they are as last comers driven to the hardest work, the lowest 
wages and the most precarious employments, to which is added the 
nervous overstrain of a change of environment, loneliness and all the 
concomitants of the stranger in a strange land. 

The practical result is that in dealing with this disease beyond 
any other we face the social problem of incipient pauperism. A highly 
organized bureaucratic military state like Germany, where private 
initiative and liberty are necessarily sacrificed to order and efficiency, 
meets this peril by its system of sick insurance. With us there is grave 
danger of developing the consumptive rounder by indiscriminate re- 
lief. Hospitals, dispensaries and medical relief in general do less in 
the examination of the needs and conditions of patients than any form 
of charity whatever. Grave danger exists that in our anxiety over 
a disease, we shall pauperize a family in seeking to save an individual. 
What should be done in our cities is by the combination of hospitals 
to create a central bureau for the examination of all cases for free re- 
lief and employ the aid of friends and family before trenching on 
charitable resources never large enough for the real needs of society. 
A specific organization of aid to the consumptives is needed at this 
point to avoid pauperizing an entire social stratum by making chronic 
illness an open passport to relief. Only for a season will this be neces- 
sary. Individual cases call for individual aid. At the early initial 
period $ioo will bridge the gap from disease to recovery. This fact 
needs to sink into the public conscience. Not a family, not a person 
among the well-to-do but sees some case in those employed that can 



34 NAT. ass'n for study and prev. of tuberculosis 

be saved if air, leisure, and food are provided. In Germany 70 per 
cent, of early cases are saved. Given individually this will not pauper- 
ize and personal responsibility for the recovery of some one case needs 
to be enforced and brought home on the entire class of employers. 

These things are all possible because it is a winning fight, a 
decreasing disease, a malady against which all the better social forces 
are warring. Let the accelerated decrease of the last 30 years continue 
for another 30 and the disease will have begun wholly to disappear. 
The " White Plague " will pass, as the plague of the East has been 
expelled from civilization. 



SOCIOLOGICAL SECTION 

Chairman 
HOMER FOLKS 

New York 

Secretary 
LILIAN BRANDT 

New York 



HEALTH AS AN INVESTMENT 

By Homer Folks 
New York 



The important facts with which the sociological section of this 
association would naturally have to do may be stated in general terms 
without difficulty. First, tuberculosis is the leading cause of death 
in this country. It cuts down its tens of thousands and its hundreds 
of thousands in the prime of Ufe. The tragedy in the life of the indi- 
vidual consumptive — apprehension deepening into terror, the possible 
and then the probable misfortune to wife and children almost too ter- 
rible to be thought of, the weakening of the vital forces, the ever 
renewed hope, and hope against hope, the gathering shadows, and the 
final dissolution — a story whose pathos is such that no brush or pen 
can picture it, is repeated so often that the very mass of it dulls our per- 
ceptions and our sympathies. Other chapters of the story may be 
found among the beneficiaries of our charitable societies, the lists of 
the recipients of public outdoor relief, in the orphan asylums and in 
the hospitals, and in laundries and kitchens where overworked mothers 
are striving desperately to support their fatherless children at the ex- 
pense of their own life energies.. Fortunate for us that our imagina- 
tions are so feeble, our knowledge so imperfect, that only a few nooks 
and corners of the enormous area of desolatioti wrought by this dis- 
ease come to our notice. 

The second great fact is that in the past two or three decades we 
have learned some of the most important secrets of the arch enemy. 
We have discovered the unit of his forces, and we know something 
of its nature. We know how these units are marshalled into line, 
how they lie in wait, always ready to enter upon and then fully occupy 
any promising territory. We also know how to apply this knowledge 
in practice. We know how to cure a large proportion of those who are 
attacked, if only they can be treated in time. We know how to capture 

37 



38 NATIONAL ASSOCIATION FOR THE STUDY 

and destroy the active agent in the spread of infection. While we hope 
that the things we have learned are only a foretaste of the discoveries 
that are to be made in the very near future, they are sufficient to form 
the basis of a working program, subject always to revision as addi- 
tional light is gained. The steps that should be taken in the application 
of our present knowledge to the restriction of this disease have been set 
forth lucidly and specifically in several notable papers, nowhere, per- 
haps, more clearly and comprehensively than in Dr. Biggs's paper on 
Administrative Control of Tuberculosis, delivered under the auspices 
of the Henry Phipps Institute, February, 1904. 

Considerable progress has been made, and is being made, in 
carrying into effect some or all of these administrative measures in 
various localities, nowhere, probably, in greater degree than in New 
York city. The result is read in the very notable decrease in the death- 
rate from pulmonary tuberculosis in New York city (Manhattan and 
the Bronx) from 3.86 per thousand in 1884 to 2.46 per thousand in 
1904. After careful study of the possibilities of error and the differ- 
ence in diagnosis at different periods, Dr. Biggs (and I can quote no 
higher authority) states that the " conclusion seems to be thoroughly 
substantiated that the decrease in the deaths from tuberculosis is a 
real one and not in any material respect merely apparent." That this 
decrease is due in part to the general improvement of living con- 
ditions not included in the measures directed specifically against 
tuberculosis, is undoubtedly true. It is sufficient vindication of, not to 
say an extraordinary testimonial to, the campaign against tuberculosis, 
that it has contributed in some material degree to this wonderful 
result. 

There is danger, however, that ^in our gratification at what has 
been accomplished we may underestimate that which remains to be 
done. Although pulmonary tuberculosis has in places and at times 
yielded the primacy among the causes of death to that group of diseases 
known as pneumonia, I believe it has nowhere fallen below the place of 
a close second. The question which inevitably occurs to a layman is this, 

— if tuberculosis is a preventable disease, why is it not, in a still larger 
degree, prevented? If in its earlier stages it is usually curable, why 
are not more consumptives cured? Why did we record 8,512 deaths 
from phthisis in New York City in 1904? Various answers are given, 

— that the public is not yet sufficiently informed as to the means of 
preventing the spread of infection; that people are not as yet suffi- 



AND PREVENTION OF TUBERCULOSIS 39 

ciently educated as to the value of hospitals and sanatoria ; that 
patients do not seek medical advice at a sufficiently early period; or, 
that, if they do seek it, the disease is not recognized by the ordinary 
practitioner; that our houses are not sufficiently ventilated, especially 
at night; and many other answers, all of weight. After some reflec- 
tion, I am forced to the conclusion that all these reasons for the con- 
tinued prevalence of this preventable disease may be resolved into one, 
namely, that we do not realize the value of public health as an invest- 
ment ; that we are not yet ready to devote sufficient means to the sav- 
ing of human life, even when the opportunity is placed squarely 
before us. Which of the ten measures set forth by Dr. Biggs in the 
paper already referred to is fully carried into effect, even in the city 
of New York ? A few of them requiring comparatively little expendi- 
ture, are probably as effective as the present willingness of the medical 
profession to co-operate will permit. But in all the very important 
measures, which involve the expenditure of large sums of money, it 
is only too evident that our present provision is very ineffective and 
incomplete, and in some very important directions almost grotesquely 
inadequate. Whenever you push the inquiry as to the occasion of this 
inadequacy, you almost immediately come back to the underlying cause, 
the lack of adequate means. If money is the sinews of war, it certainly 
is the sinews of this warfare in which we are engaged. We have the 
greatest possible respect for the efficiency, the expertness, and the 
devotion to the public well-being, of our health authorities, but they, 
and we, must admit that the sums of money placed at their disposal, 
or at the disposal of any of their co-operating agencies, are wofully 
inadequate for the performance of the tasks which we all know are 
essential in checking this disease. 

Consider the question of tuberculosis dispensaries, for instance. 
In only one of the five boroughs of the city is there such a thing as 
a tuberculosis dispensary, and in the Borough of Manhattan there 
should be five times as many as there are. And as to the few that we 
have, how many of them provide all the treatment, oversight, care, 
assistance in the home, and food that are clearly indicated as needed? 

As to the educational campaign, thousands of circulars have been 
printed in many different languages, but to what extent have they 
actually reached the hands of the three and three-quarters millions of 
people in Greater New York ? In a political campaign each individual 
registered voter is reached through the mail, not only once but several 



40 NATIONAL ASSOCIATION FOR THE STUDY 

times. The postage alone for a single communication, unsealed, to 
the registered voters costs the tidy sum of over $6,000, to say noth- 
ing of the printing, addressing, folding, etc. This particular method 
might not be the best for our purposes, but I doubt whether any less 
expensive one will be really effective. When we have at our disposal 
the means to undertake a few jobs of this magnitude, then we can carry 
on a campaign, and not merely a skirmish, of education. 

As for the care of consumptives in their homes, with sufficient 
food of the right sort and adequate medical and nursing oversight ; ag 
to the provision of sufficient hospitals, sanatoria, and employment of 
convalescent patients, we are only at the beginning. Of all that has 
been done — and much has been done — we are, we trust, duly appre- 
ciative : but let us not forget that all that has been done is but a small 
part of that which should now be undertaken. 

The practical question, then, is shall we as a community, knowing 
how to restrict effectively this terrible scourge, be satisfied with the 
piecemeal method, advancing slowly, a step here and a step there, 
wheedling a few additional thousands of dollars year by year from 
our city authorities and from the pockets of the well-to-do? Or shall 
we recognize the extraordinary nature of the situation created by our 
recent discoveries, make the largest possible use of our precious, 
recently acquired knowledge, and by large expenditures accomplish 
the greatest result in the shortest time? 

I speak of New York city more particularly, because of greater 
familiarity with its circumstances, but the same considerations apply 
to all our cities. A unique opportunity is offered to our municipalities 
for the complete application of our present knowledge of tuberculosis, 
and of that additional knowledge which we shall undoubtedly gain 
from year to year, as we apply that which we now have. Why should 
not the city of New York spend a million dollars yearly for the next 
ten years, in order to do effectively, and adequately, the task set before 
it by competent medical authorities, for the restriction of tuberculosis. 
An addition, for this purpose, of a million dollars to the annual budget 
of New York city, already amounting to considerably over one hun- 
dred millions, ought not to be impossible; though, humanly speaking, 
perhaps it is. The fear of the taxpayer, the disinclination to discover 
and apply new modes of taxation, is so great that perhaps such an 
addition to the current expense account of New York and, in propor- 
tion, in other large cities, would be, politically speaking, impossible. 



AND PREVENTION OF TUBERCULOSIS 4 1 

But there is another possibility. When the city is undertaking a 
great public improvement the benefits of which will be extended over 
a series of years, perhaps through one or more generations, it does not 
meet this expenditure from its current funds, but from the sale of cor- 
porate stock, the burden of which is distributed over a series of years. 
Schoolhouses, hospitals, bridges, subways, and all these other great 
public enterprises are provided in this manner. They are spoken of 
as " permanent " improvements, made possible by the use of the credit 
of the city for the benefit of its people. Many of these investments are, 
directly or indirectly, for the health of the pople. In providing parks 
and playgrounds, baths, hospitals for the care of contagious and other 
diseases, and, in an ever greater variety of ways, the city is pledging 
its credit for public improvements for the sake of promoting the gen- 
eral well-being. 

Why should not an adequate expenditure for the restriction^ of 
tuberculosis by all of the known methods be of exactly this character, 
and therefore an appropriate expenditure to be defrayed from the sale 
of bonds? Certainly, the need is of a more unusual and extraordinary 
character than those I have indicated. Schoolhouses, hospitals, facili- 
ties for transportation, are constantly recurring subjects of expendi- 
ture, but it is only once or twice in a century that we acquire substan- 
tial control over an additional disease among those that stand high 
in the list of the causes of death. There is every reason to believe that 
after the work had been carried on adequately, efficiently, and com- 
prehensively for a term of years, the need therefor, in some respects 
at least, would greatly diminish. What better use of the city's credit 
could possibly be made, what benefit would be more widely dissemi- 
nated, or extended through a longer period of time ? 

What we often call " permanent improvements " are, after all, of 
a temporary character. The lifetime of a great* structure can be fore- 
told with approximate accuracy ; schoolhouses become unsuitable and 
obsolete and are torn down ; hospital buildings give way to better and 
larger buildings ; but substantial restriction of tuberculosis, such as we 
have ample reason to believe would be secured by really doing what we 
already know how to do, would be of untold benefit to generations 
yet unborn. When we speak of " permanent " improvements, why do 
we always think of brick and mortar, granite and steel ? These things 
are of service only because they contribute to human well-being, and 
they are not the only means through which the city contributes to the 



42 NATIONAL ASSOCIATION FOR THE STUDY 

well-being of its people. Every step taken for the protection of the 
health of the people, the protection of its food supplies, the care of its 
sick, the improvement of its housing conditions, protection from moral 
evils, is a great public improvement. If we can select from among 
these opportunities for the promotion of the general well-being, those 
that are of an unusual character, those that present extraordinary- 
opportunities, and whose benefits extend long beyond the period in 
which the expenditure is incurred, have we not a group of objects for 
which public indebtedness may properly and wisely be incurred ? Addi- 
tional legislative authority might be necessary to enable municipalities 
to incur debt for this purpose, but there is no reason for thinking that 
such authority would not be granted if the matter were brought in a 
proper way before our state legislatures. 

It is true that when the city invests money in a public park the 
real estate remains and the investment could be converted, should it be 
so desired, into cash. But this is not true to any appreciable extent of 
most of the objects for which public indebtedness is incurred. The 
money invested by the city in its great public improvements is invested 
beyond recall, and while there remains in some cases more, and in 
most cases less, of actual value to support the city's credit, does it not 
remain true nevertheless that the ultimate foundation of that credit rests 
in the people of the city, and not in its property? 

The benefits derived from large expenditure for the public health 
could not, it is true, be converted into cash, but it is not the habit of 
our cities to go into liquidation, and while the public health is not an 
available asset in this sense of the word it is nevertheless an economic 
asset of the highest possible value, contributing to the economic 
strength of the people, furnishing the foundation upon which the en- 
tire superstructure of municipal credit and life is built. A strong 
people, relieved of unnecessary burdens caused by sickness and death, 
can bear other and larger burdens of taxation for public purposes. 
From every point of view therefore it seems to me that no American 
city at the present time can find a more appropriate subject for per- 
manent investment, yielding larger returns, than in carrying into effect 
the measures set forth at this meeting of the National Association for 
the Study and Prevention of Tuberculosis. 

This is not, however, exclusively a question for the city. It is also 
in large degree a question for private benevolence. The establishment 
of more and bettei sanatoria, the maintenance of more and better tuber- 



AND PREVENTION OF TUBERCULOSIS 43 

culosis dispensaries, the assistance at home of the consumptive who 
cannot be removed to a hospital, the care of the family whose wage- 
earner is under treatment, and certain portions of the educational cam- 
paign, are as appropriate for private initiative as for public action, if 
not distinctly more so. What we need for these purposes is not large 
permanent endowments, nor moderate annual contributions for an 
indefinite period. The need is for unusually large contributions for a 
comparatively brief period. The citizen of New York who will set 
aside a sum of money which, together with the income upon the unex- 
pended portion, will provide half a million dollars a year for each year 
for the next ten years, will write his name large on the future history 
of the metropolis, will show himself a profound student of social well- 
being, a wise judge of the merits of various possibilities in the invest- 
ment of his money. And in every city, large and small, the men of 
means, who feel the call of the social spirit, can find no better subject 
for contemplation and prayerful consideration, than this which we are 
considering. Let us hope that the founder of the splendid Henry 
Phipps Institute of Philadelphia will be but the first of a long line of 
public benefactors who will thus supplement the work of our munici- 
palities. 

We are a great people, at least so we are told. Our resourceful- 
ness, energy and capacity for organization are said to be the wonder 
of those whom we have passed in the race for industrial supremacy. 
We do large things in a large way, and get large results quickly. We 
see great opportunities, appreciate the bearing of new discoveries, and 
move quickly, and in the right direction. Have we not now before 
us the greatest opportunity of all, an opportunity to invest a very small 
proportion of our free capital in a manner which will yield large and 
quick returns in the prevention of suffering, disease and death ? Let us 
not proceed in any halting, half-hearted, untertain manner in the 
accomplishment of this task for whose performance we now have, for 
the first time in the world's history, the necessary scientific guidance. 



DISCUSSION ON MR. FOLKS'S PAPER 

Dr. Thomas Darlington, New York: I must confess that it is 
with some diffidence that I rise to say anything upon this subject as 
it was not my intention to speak upon any subject before the Asso- 



44 NATIONAL ASSOCIATION FOR THE STUDY 

ciation. Still it has been impressed upon all that we should do what 
we can to be of assistance. 

I certainly must agree with the chairman and the writer of the 
paper on many points and especially that it is simply a question of the 
education of the masses before tuberculosis can be stamped out in the 
cities of the United States. It is merely a question of money because 
with plenty of money you can have all the education necessary and 
with this education tuberculosis can be entirely gotten rid of. It means 
the amelioration of conditions and environment. The scriptures say 
" all that man hath will he give for his life." Life is man's birthright 
and we have a right to expect it in any community. We give so much 
to education. What advantage is it to have higher education but a dead 
child ? It is necessary for the community to take care of those who do 
not take care of themselves on many grounds. Christ teaches that 
" thou shalt love thy neighbor as thyself," and on this teaching rests 
the sanitary laws of the country. Health means ability to work and 
earn wages and that is everything to the community. Why, then, 
should you not spend more upon health than upon education? Surely 
the amount spent upon health is small in comparison with the work 
accomplished and it should be doubled. 

We have a great problem to deal with in the large cities like New 
York, especially in educating the people who cannot read the English 
language. The death rate from tuberculosis is increasing. Why? 
Because among 289,000 emigrants to this country nine-tenths of them 
have stayed in New York City, and these must be educated. How are 
we going to do it? Circulars must be printed in English, in Russian, 
in German, in French, in Hungarian, in Slav, in Chinese, etc., and this 
involves a great expenditure of money. Does it not pay ? What is lost 
in wages when a person is sick with a communicable disease ? What is 
lost in education to a child at home for an indefinite period with tuber- 
culosis or lung disease ? Is it not reasonable to expect the city to spend 
more for matters of health ? At the tuberculosis clinic that is attached 
to the New York Board of Health, among 3,000 patients treated last 
year, 1,100 of them were Russians who had been in this country only 
two years. How very difficult it is to teach people of this character! 
It is necessary not only to give circulars that they can read but also that 
their homes should be investigated and bad conditions corrected. But 
all this costs money. Of course, when it is suggested that we give 
millions a year towards the stamping out of tuberculosis the fact should 



AND PREVENTION OF TUBERCULOSIS 45 

not be lost sight of that there are other things which require the expen- 
diture of money. The question of amount of money is a serious one 
for your consideration, and the amount spent in stamping out tubercu- 
losis I believe would be doubled or even quadrupled by the returns^ from 
increased ability to earn wages. I do think it would be economy to 
issue bonds for this work in our large cities. 

I have an unlimited hope and an abiding faith in our people. The 
amount of money given for this work should be considered as a legacy. 
But if we are to really gain anything it depends upon some Society such 
as this, where we can meet and discuss papers, and upon the moral 
support given by this Government and that of other countries. If such 
an organization as this will stand firm behind its officers, then I believe 
we will obtain a higher, a nobler and a healthier civilization. 

Dr. Antonio Stella, New York : The forceful presentation of facts 
which has just been given by Dr. Darlington and of the conditions 
which are present in our immigration population, leads me to say a few 
words in behalf of the Italian element and the Italian immigrants, espe- 
cially in New York City. In order to have a better conception of 
the importance, the vital importance of this, it might be well to re- 
mind you of the large population of the Italians in the United United 
States, but more particularly in New York City. According to the 
calculations of the Italian Chamber of Commerce in July, 1904, the 
number of Italians resident in New York City represent an army 
numbering 384,704, almost 400,000; this number is nearly as large 
as the population of the second largest city in Italy. The majority 
of this Italian population have a tendency to be sick. It is impor- 
tant to know, too, that 72^0 of the Italian immigration reside in the 
larger cities. Restricting my observations to New York City, there are 
about 400,000 Italians there, and it is a well known fact among phy- 
sicians in general, as well as social workers, that the prevalence of tu- 
berculosis among them is exceedingly great. This prevalence of tuber- 
culosis among these people cannot be detected by a study of the vital 
statistics because when once informed that they have tuberculosis, es- 
pecially the pulmonary form, they right away decide to return to their 
native country and, therefore, escape tabulation in the New York 
Bureau; this makes the statistics regarding the Italian death rate a 
deceptive one. The discrepancy between the statistics of the Health 
Board and the real conditions are due to this fact alone. An approxi- 
mate estimate of the prevalence of tuberculosis among Italians in New 



46 NATIONAL ASSOCIATION FOR THE STUDY 

York City can be had by studying the morbidity and not the mortaUty 
of the disease; it will then be shown that the Italians in this country 
are very susceptible to all forms of tuberculosis. I tried to obtain some 
positive data on this subject, but the only way to do so was to get it 
from the various dispensaries and hospitals by studying their records. 
There has been an attempt to keep accurate records of tuberculosis as 
it affected the various nationalities at the Columbian Hospital. In 1903 
out of 11,157 admissions there were no less than 107 cases of tuber- 
culosis, surgically speaking, among the Italians. This hospital refuses 
all other than surgical cases of tuberculosis, and this makes the percen- 
tage appear to be a very small one. Among those refused two-thirds 
were affected with tuberculosis. In 1904 the New York Hospital re- 
ceived 547 Italians ; out of the whole number of admissions, including 
those that were received after operation, there were no less than 64 
who had surgical tuberculosis. Cases of general tuberculosis were al- 
ways excluded. 

Mr. Charles F. Weller, Washington : I take it that there are but 
two cities in the United States in which every one is interested — New 
York, the leading city, and the other that commands interest is Wash- 
ington. The national capital has an exceedingly high death-rate from 
tuberculosis and opinions differ as to what that death rate really is, but 
according to the Bureau of Labor statistics in 1892 the death rate from 
tuberculosis in Washington is exceeded only by two cities among forty 
large cities, viz., Los Angeles and Denver. I wish to mention this to 
show how great the death rate is from one of the preventable diseases. 

In the District of Columbia we have repeatedly had important legis- 
lation prevented by one or two Congressmen, often from states even 
smaller than the national capital itself. Therefore, we make an appeal 
to the public to send us people who are informed as to the needs of 
modern preventive social measures. If you do not educate them before 
sending them, please educate them afterward and let them hear from 
you that you deem it necessary that they should support measures for 
the prevention of tuberculosis in this city. Please bear this in mind and 
help us in our efforts for proper legislation. 

Mr. Christopher Easton, Newport, R. I. : The doctors in Newport 
are trying to educate the people regarding the danger from tubercu- 
losis and leaflets have been sent to every house there. I also wish to 
state that we spend, or did spend until quite recently, more money for 
leaflets and lectures than we did for food, i. e., extra food. One of the 



AND PREVENTION OF TUBERCULOSIS 47 

speakers this afternoon referred to birthrights, and I do not think it 
would be at all improper to speak of other birthrights than those re- 
ferred to, such as knowledge, science, duties, etc., and we should try to 
get these birthrights even though they are only to be had through efforts 
made by this society. Birthrights must be enjoyed. 

The Chairman : Do you consider that money spent on circulars of 
information is money well spent? 

Mr. Easton : I cannot say ; but I will say that every individual in 
the city has some knowledge of tuberculosis. 

The Chairman: We usually look to the city of Boston as to one 
leading the way to progress. 

Mr. A. M. Wilson, Boston : The educational campaign in Boston 
has been going on with vast strides and we are now working to have 
large sums given us for consumptive hospitals. For advanced cases of 
tuberculosis there are only two or three places where they can be sent, 
besides the almshouses. One of the greatest needs today is suitable 
provision, municipal provision, for advanced cases of consumption and 
a bill recently presented to that end was held up by the Mayor. 

Dr. Hermann M. Biggs, New York : In New York we are better 
treated by the authorities in the way of providing funds than in most 
municipalities. I do not mean to say that we have all the money we 
want but recently we have had as much money as we could wisely 
spend. I think that we should not lose sight of the fact that in this 
work education must precede any judicious expenditure of money. We 
cannot carry on our work much beyond the plane to which the medical 
profession has been educated. A large part of the work done has been 
done before any information as to the existence of the cases was to be 
had; in fact, many of the cases of tuberculosis had been under treat- 
ment for a year or a year and a half before the nature of the disease was 
recognized, and during that time the infection* had been disseminated 
and the greatest possible harm done. Now we can carry on the work 
somewhat beyond the point to which we have trained the profession and 
the profession has become educated so as to make an earlier diagnosis. 
Further, the education of the people demands an earlier recognition 
of the disease and this is of fundamental importance ; the people demand 
a more critical examination of the sputum in cases of chronic cough 
and they demand as much care as the advancement in medicine justi- 
fies. We find there are a large number of people coming to the clinic 
not for treatment, but for diagnosis ; they come there from all parts of 



48 NATIONAL ASSOCIATION FOR THE STUDY 

the city. They have had a cough for several months and have not been 
satisfied with the sort of treatment and examination they have had. 
They come in and ask whether or not they have tuberculosis. It is this 
sentiment that raises the whole plane of treatment in tuberculosis. 

There are many things which require money as, for instance, pro- 
vision for institutions ; but there is no use in such provision unless the 
people have been educated to come to such institutions. It has been 
only during this last period of two or three years that a large part of 
the population in New York City has been educated to avail themselves 
of the facilities for the care of consumptives that we offer. The census 
taken about three months ago shows that there were 1800 consumptives 
under treatment in public and private institutions in New York City. 
Still there yet exists great difficulty in getting people to go to these in- 
stitutions. Of course, if we could supply them with sanatoria under 
the best possible conditions I believe that a large number would con- 
sent to go, more than now. But from the standpoint of prevention it 
should be remembered that it is the late case that is the more important 
hfid the one that demands our care. 

As to the advisability of issuing corporate stock it is well worth 
serious consideration and I doubt whether, under the present laws, the 
Board of Estimate has that power. I think they are restricted as to what 
calls for moral betterment and whilst this betterment is of the highest 
character I doubt if they would have the power to authorize the issuance 
of corporate stock for expenditure on educating the people or doing 
anything that would afford temporary relief of tuberculosis. 

Dr. J. H. Lowman, Cleveland : It is very necessary to have money, 
but it is really extraordinary what can be done with a very little money. 
While you are waiting for funds it is still necessary to work, and I here 
should like to call attention to the work that is being carried on by a 
certain gentleman in Cleveland. His particular desire is to get children 
into the country and away from tuberculous families. It is not neces- 
sary that these children should themselves be tuberculous to avail them- 
selves of this privilege. Last summer he sent into the country children 
that needed the air and kept them there for two weeks or two months ; 
960 children were sent at an expenditure of $102.00. They are carried 
there free by the railroads and are taken care of. All that this gentle- 
man has contributed has been his own time and it is his desire to occupy 
himself in this manner. This method of getting children away from 
infected families is carried out in Denmark. At Copenhagen 17,000 



AND PREVENTION OF TUBERCULOSIS 49 

children have thus been taken care of and at a small expense. This 
gentleman works in conjunction with the Anti-Tuberculosis League of 
Ohio, and he works with and for the children's division of that league, 
and at a very small expense to himself. 

Mr. Elwell Stockdale, White Haven : In Pennsylvania the bill for 
tuberculosis has been cut to nothing. What is discouraging to most 
people is to set out to cure tuberculosis without lots of cash. The ef- 
forts to control this disease in Philadelphia should be copied by every 
city; every town should have its tuberculosis association. At White 
Haven the cost per head of caring for these patients is $125.00. When 
we started in this work we ran up nothing but bills ; the next summer, 
however, we ran the whole institution of 100 patients on a capital of 
$1.00 per head. It seems to me that tuberculosis must surely go and 
shortly. It might be interesting to state that I was a consumptive and 
was given up as a hopeless case. 

In Philadelphia recently an auxiliary was formed with the object 
of collecting money for the pursuance of this work, anywhere from 
$1.00 to $100.00 a year being asked. Any one who gave $100.00 a year 
was informed that that amount would save one life. I think it depends 
upon ourselves entirely to take up this matter and not to look to the 
state or city, as New York does. We should shoulder the burden our- 
selves and make strenuous effort to cure a disease which we know can 
be cured and with so little money. 

Dr. S. A. Knopf, New York: I would not have arisen if the 
•last speaker had not showed such an optimistic view of the subject. 
Take that excellent institution in New York, where Dr. Trudeau works 
and has been working for fifteen years, they cannot possibly cure a 
•consumptive for less than $7.00 or $8.00 a week. I do not think that 
we should allow the laymen to think that we can cure consumption for 
$125.00 a year. If we wish to attack this tuberculosis problem cor- 
rectly we should look upon all its phases; we should begin with the 
education of the people regarding this disease, we should look out 
for the children, etc. How to get sufficient money for all this work 
I do not know, but I would advise following the plan that has been 
adopted in the little state of Delaware ; as a result of their scheme they 
are able to care for their consumptives better than any state in the 
Union. 

I hope my voice will reach the ears of some philanthropist who 
will aid us in caring for the consumptive poor. 



50 NAT. ASS'n for STUDY AND PREV. OF TUBERCULOSIS 

Mr. Elwell Stockdale, White Haven : When I spoke of the results 
obtained in Pennsylvania I did not intend to make any comparison with 
Dr. Trudeau's sanitarium, an excellent one carried on as a hotel, with 
everybody on the premises paid. In the institution I was referring to 
the only ones paid are the nurses and myself. The cost there is $5.00 
per week per capita. 

Dr. Henry B. Jacobs, Baltimore: In Maryland the cost for the 
care of the tuberculosis patient is about $8.00 per week and we are able 
to send patients for three months' treatment on an average. The earlier 
cases require about three months' treatment at a total cost, therefore, of 
$96.00. At $96.00 per head we feel that the public will realize and 
appreciate what can be done for a not very large sum of money and, 
therefore, we may get more subscriptions and so be enabled to save 
more lives. 

Mr. Homer Folks, New York: In speaking on the subject of 
corporate funds it is not so much a question of the power of any 
particular municipality as it is the wisdom of the general policy. Each 
city has varying degrees of authority as confirmed by the legislature 
of the state and in most cases, particularly in the State of New York, 
the power to increase the indebtedness is given from time to time. It 
might be well to secure an amendment to the charter to get permission 
to use the city's credit for this purpose, just as was done in the case of 
the Subway and other public improvements. 

Dr. Irving Fisher, New Haven, Conn. : A paying investment im- 
plies not so much the cure of tuberculosis as it does the ability to return 
to work, and I think Dr. Biggs has supplied the data. Suppose that it 
costs $100.00 to cure a patient. Without being cured that patient 
would require $300.00 before he died, losing $1.00 a day because of 
loss of work, $1.00 a day for medicines and care, etc. Suppose the man 
to be in middle life, he should be able to make every working year 
$1500 or $2000; now an investment of $100 for a return of possibly 
$2000 is certainly worth while. 

In New Haven we have a Tuberculosis Association, of which I 
am the Secretary ; we have 400 deaths a year and applying this calcula- 
tion we find that there is a loss of $200,000 a year in cold cash from 
tuberculosis. It certainly does not cost anything like that to prevent the 
disease. The return from such an investment would not be 5% but 
something like 5000%. 



A WORKING PROGRAlM 

for associations for the prevention of tuberculosis — national, 

state and local 

By Edward T. Devine, Ph. D., LL. D. 

New York 



It is one hundred and one years since Sydney Smith, the caustic 
reviewer and indefatigable reformer, astonished the members and sup- 
porters of the British Society for the Suppression of Vice by an article 
in the Edinburgh Review attacking the fundamental principle upon 
which that and all similar societies are based, turning their axioms ruth- 
lessly upside down and inside out; convicting them of sectarianism, 
hypocrisy, tyranny, arrogance, and injustice; administering much 
wholesome reproof and admonition, and concluding by the assurance 
that if they would attend to " these rough doctrines, they will ever find 
in this journal their warmest admirers and their most sincere advocates 
and friends." 

There is one initial difference between the society which Sydney 
Smith satirized and that which we are founding. The suppression of 
vice meant, of course, or appeared to mean, the prosecution of the 
vicious. The suppression of tuberculosis means, not persecution, but 
help for the individual consumptive. The machinery of the law must 
be invoked in our case as in theirs, but it is* the law in its most 
benignant aspect, with stern compulsion in the background always, but 
in the foreground the kindly physician, the uniform of the nurse, the 
educational leaflet, the persuasive talk, and for those who are not ill, 
freedom from preventable infection. 

The ultimate responsibility for the control of epidemics, as for the 
cure and prevention of disease in general, hes with the medical pro- 
fession. To our medical brethren this may appear a hard saying and, 
as I shall show, it requires qualification. It is nevertheless the large 
truth and the controlling truth to which all other considerations are 

5^ 



52 NATIONAL ASSOCIATION FOR THE STUDY 

subsidiary. Just as it is the duty of the business man to do business, 
and not to cheat; just as it is the duty of the philanthropist to do good, 
and not to pauperize ; so it is the duty of the physician to cure disease 
in the individual, and not to permit epidemics. It is indeed conceiv- 
able that a physician may refuse to recognize any social obligation, 
and that his vision may be limited by the terms of the contract between 
himself and his individual patient, just as the philanthropist may insist 
upon dabbling in a particular form of distress which appeals to his 
sympathies, and refuse to consider the relatively greater needs at his 
side, or even the possibly injurious social effect of his actions. But 
the medical practitioner of this type is false to the lofty traditions of 
his own profession, which may well challenge comparison with other 
callings as to the measure in which it meets its social obligations. 

The problem, then, for laymen, for legislators and public officials, 
for the public press and other instruments for the moulding of public 
opinion, in relation to the scourge of tuberculosis, as in relation to any 
other great epidemic may be defined to be the centering of complete 
responsibility upon the medical profession. This, however, cannot be 
done merely by logical demonstration as to what their duty is, by hyper- 
critical fault-finding as to the manner in which it is being discharged, 
or by eloquent exhortation to physicians to attend to the matter. Re- 
sponsibility can be devolved upon the medical profession only by 
meeting the conditions which authoritative medical opinion prescribes 
as essential. 

For example, when it has been shown that hospitals and sanatoria 
are necessary, it is no more the duty of physicians than of others to 
secure their establishment. Physicians must do their part, according 
to their abilities, like other citizens; but the only way in which the 
complete responsibility for procuring results can be placed squarely 
upon the shoulders of the medical profession as such, is for the state, 
the municipality, or private philanthropy to provide the hospitals and 
the sanatoria which authoritative medical opinion has declared to be 
indispensable. Again, when appropriations for sanitary inspection, 
for the enforcement of anti-spitting ordinances, or for special inves- 
tigations are demanded, upon reasonable and conservative grounds, it 
is only by making the appropriations and paying the taxes which they 
necessitate that the community transfers to the medical profession 
responsibility for results. It is clearly the duty of representative medi- 
cal men not to demand the impossible, but to subject to rigid pro- 



AND PREVENTION OF TUBERCULOSIS 53 

fessional criticism the actions of officials or experts who are using such 
appropriations, and to see that expenditures are made in such a manner 
as to ensure maximum results. 

So far as the movement for the prevention of tuberculosis is con- 
cerned, there is little difficulty in formulating a positive program. 
It has at least ten features : 

1. The maximum of sunlight and fresh air for all mankind — at 
work, at leisure, and at sleep, and if there be any other occupation than 
these three, then while engaged in those other occupations as well. 

2. An abundance of simple, and yet sufficiently varied and nour- 
ishing food, especially — to put it concretely — of pure milk and fresh 
eggs. 

3. Early diagnosis of every case of pulmonary tuberculosis by 
the family physician, and the utmost attempt to secure compliance with 
his advice as to medical treatment and diet, change of work or com- 
plete release from regular employment, change of residence, or removal 
to sanatorium or hospital — such advice naturally taking into account 
all the circumstances of the individual patient. 

4. Registration of all cases, whether in tenements or palaces, 
whether in city or country — not to be followed by any unnecessary 
interference by health board inspectors or nurses, if there is a physi- 
cian in charge, or by any other invasion of privacy or other personal 
hardship — but enabling the duly constituted health authorities to know 
their problem and to deal with it on the basis of complete knowledge. 
I am aware that in many communities this is a counsel of perfection, but 
it is a part of our program. 

5. The establishment of hospitals, or hospital wards, or houses of 
rest, or whatever other institution will best serve the purpose for 
advanced cases, with two primary objects in view: to make such 
patients more comfortable in their last months, and to diminish the 
centers of active infection. 

6. The establishment on a generous scale of state, municipal, and 
private sanatoria for the treatment of patients in the earlier stages, 
cases promising either cure or at least arrest of the disease, and radi- 
cal improvement of general health — no expense being spared so far 
as essentials are concerned, no extravagance being tolerated in non- 
essentials. 

7. Publicity as to the means of preventing infection, and as to the 
other elementary rules of hygiene, through every known channel of 



54 NATIONAL ASSOCIATION FOR THE STUDY 

public instruction : newspapers, schools, the lecture platform, leaflets in 
all necessary languages, appropriate special periodicals, and instructive 
visits from physicians, nurses, or competent lay visitors. 

8. Conferences for interchange of views and experiences among 
those who in any way, however humble, are working at the common 
task and associations for educational and preventive work. 

9. Relief in various forms, but especially in the form of special 
diet for those who can and must be treated at home, rather than in 
sanatoria, and who are without sufficient income to provide for the 
necessaries of life — which in some cases include the prescribed diet 
essential to life and recovery. 

10. And finally, further research. Even here, where I am a rank 
outsider, I must round out my statement of our general program. 
We need more knowledge, better authenticated records, further com- 
parison of results, ever more and more accurate knowledge — and for 
these we must have laboratories, endowments, and favorable condi- 
tions for scientific research, travel for observation and study abroad, 
and training for fruitful investigation. 

In these ten tasks each society, each committee — nay, each indi- 
vidual who joins us may take a direct personal interest, and to any or 
all of them he may directly or indirectly contribute. It is not for any 
learned academy to say that the next discovery may not be made by 
the unknown student, or the local practitioner. It is not for the most 
powerful health board to be sure that some unknown health officer 
in a remote rural community may not hit upon the best working plan 
for securing co-operation of patient and citizen. The best leaflet for 
popular propaganda may be written in the office of the national asso- 
ciation, or it may be hammered out in the brain of a busy inspector 
pushing up one dark stairway after another, or it may come to light 
in the long drive of a country doctor, who has time to think between 
calls. And when it is written, whether by one who approaches the 
subject from a medical standpoint or by one who writes from the 
social and educational point of view, it is equally the property of all 
the rest. The law of copyright is superseded in this field, as the patent 
law gives way in the medical profession, to the higher code. 

Fortunately there is no single procedure for an anti-tuberculosis 
campaign in any community. If the actual history of the movement 
in the cities and towns represented in this meeting were studied, 
they would be found to offer many very interesting and striking con- 



AND PREVENTION OF TUBERCULOSIS 55 

trasts. The only general principle is to build on local foundations, 
and to incorporate all that is good and that is applicable in the experi- 
ence of similar movements elsewhere. For example, if there is an 
active local medical society, which is accustomed to take an effective 
part in social movements, let the beginning be made there, attracting 
to itself such additional forces as are available in the community. If 
there is the right kind of health board, or health officer, let that be the 
starting point. On the other hand, a woman's club, or a health pro- 
tective association, or a civic league, or a charity organization society, 
or any similar philanthropic body may be more free to take the ini- 
tiative — always in such case, however, in co-operation with appropriate 
public authorities. The responsibility will fall back usually in any event 
in each community upon some one man or woman who has the inspira- 
tion, who feels the responsibility, upon whose shoulders the burden 
is laid. 

My remaining suggestions may be understood to be addressed 
directly to this chosen person, called from on high to undertake this 
service, called by a personal experience, or by a sense of official 
responsibility, or only by a fatal capacity for seeing a little earlier and 
a little more clearly than others see. 

To such public official or private citizen then, I would suggest 
first of all the careful reading of some pamphlet or book in which 
the general idea is fully set forth. Dr. Knopf's prize essay on Tuber- 
culosis as a Disease of the Masses, and How to Combat It; Dr. Flick's 
book on Consumption, Preventable and Curable; Dr. Hillier's Tuber- 
culosis: Its Nature, Prevention and Treatment; or the papers in the 
Handbook on the Prevention of Tuberculosis, especially — if I may 
name three without disparagement to the others — Miss Brandt's 
Social Aspects of Tuberculosis; Dr. Biggs's Tuberculosis: its Causae 
tton and Prevention; and Dr. Prudden's Tuberculosis and its Preven- 
tion — any of the books or papers named, or any one of a half dozen 
others which might be added will suffice to give the key-note of a 
preliminary campaign or skirmish. In some respects better for our 
purpose than any of these, especially for one who is already trained 
to analyze, compare, and interpret for himself, is the Directory of Insti- 
tutions and Societies dealing zvith Tuberculosis in the United States 
and Canada, in which little volume the bare facts in regard to all such 
agencies are set forth. In the introduction prepared for one of the 
divisions of this directory there are some suggestions concerning the 



56 NATIONAL ASSOCIATION FOR THE STUDY 

organization and function of a society for the prevention of tuber- 
culosis from which I venture to reproduce one paragraph: 

The need for such effort is more conspicuous in the large cities, but the 
chance for satisfactory results is greater in the town of a few thousand inhabi- 
tants. In the small town it should be possible to give proper care to every 
consumptive, to control every centre of infection, to inform the public mind 
thoroughly, and to keep up with the needs of the population as it increases. 
These needs would be chiefly in the way of education, inasmuch as the original 
provision for the sick would, if the society worked effectively, continue to be 
adequate and ultimately become unnecessary. In a large city, on the other 
hand, the great numbers of sick requiring hospital and sanatorium care, the 
far greater number of persons to be instructed, and the greater difficulty in 
securing for all wholesome conditions of living, make the task seem less hope- 
ful at the same time that they emphasize the importance of undertaking it. 
Fortunately, in a large city many agencies will be found already working in- 
directly for the solution of the tuberculosis problem, and ready to undertake 
various parts of the task. But however efficient the health department, how- 
ever plentiful the hospitals, there will always remain the work of education. 

Get early into relations with the National Association for the 
Study and Prevention of Tuberculosis, and secure a number of copies 
of some one suitable paper for distribution among those who might 
naturally be expected to become interested in a definite movement. 
Supply an editor or special writer for the local press with material 
from which an article or a series of articles may be prepared for pub- 
lication in the local newspapers. Unless it is a very exceptional com- 
munity, that has probably already been done, but it may be done again 
to renew the public interest in the subject. Find out if possible 
whether tuberculosis is in fact especially prevalent in the community 
and thus give added point to the suggestion for local organization. 
When the ground has thus been prepared, arrange for a public address 
by some one who speaks effectively with recognized authority on the 
subject. There are probably such speakers in every state, but if it 
seems likely to be more appreciated do not hesitate to invite some 
eminent physician from a distance, such as are to be found in the board 
of directors of this association, and in the numerous local associa- 
tions already in existence. Either in advance of such address or at 
the time of its delivery, proceed to organize a special committee of 
some existing body, or a new association for this particular purpose, 
whose objects and general methods will be suggested by those already 
in the field, although its scope should not be too narrowly restricted. 

When the movement has thus been officially inaugurated, with 



AND PREVENTION OF TUBERCULOSIS 57 

both physicians and laymen, both women and men in its membership 
and active in its work, there should be no delay in making a thorough 
study at first hand of the local prevalence of the disease, — whether 
it is increasing or diminishing, whether there are unfavorable housing 
or industrial conditions responsible in any degree for its existence, 
whether there are appropriate laws and local ordinances, and whether 
they are being enforced, whether there are adequate hospital and sana- 
torium • and dispensary facilities, whether the particular occupations 
of the people of the community are in any special degree responsible 
for a high death-rate from this disease, and if so whether it is because 
of their essential character, or because of accidental features which 
might readily be modified. In the Havana cigar factories, for ex- 
ample, the operatives were seated on both sides of narrow tables, thus 
facing each other, and those who coughed almost necessarily dis- 
charged the sputum directly into the face of their fellow-workers on 
the opposite side. It required only a little additional floor space to face 
them all the same way, and the removal of an unnecessary board ceil- 
ing nearly doubled the cubic air space of the factory. 

It will not be necessary to know all the facts before setting on 
foot remedial measures. Study should precede action, but it is a poor 
substitute for it. On the basis of sure knowledge, gained in part from 
fresh and independent investigation, and in part from the accumulated 
experience and observations of physicians and earlier reformers, get 
to work. You will need new laws, new appropriations, new methods, 
and sometimes new officials. You will need an educated and aroused 
public opinion, and you will need the widest diffusion of elementary 
information. You will need the co-operation and active support of the 
medical profession ; of the teaching profession from university and 
professional school to the kindergarten ; of the journalists, the business 
community, the religious and charitable fraternity, and of every other 
individual — whether grouped into classes or not — who is indignant 
at unmerited and needless suffering, and who is willing to lend a hand 
in a world-wide humanitarian movement — a movement which already 
enlists the enthusiasm of a larger number than all who marched in the 
crusades of old, which already commands greater capital than would 
provide a modern navy for a first-class power, which has already won 
a hearing at the awakened conscience of mankind, and which is never- 
theless, as yet, in its feeble beginnings, with comparatively few lives 
lengthened, comparatively little pain mitigated, comparatively few 



58 NATIONAL ASSOCIATION FOR THE STUDY 

families saved from unnecessary dependence. Those who are taking 
up the initial responsibility for these local movements should personally 
in some way connect themselves with the larger plans, and thus keep 
alive their interest in all the varied aspects of the movement. The local 
auxiliaries of Stony Wold Sanatorium, and the affiliation of the local 
Young Men's Christian Associations with the Health Farm at Denver, 
are especially commendable for the opportunity which they give to 
private individuals widely separated from each other to feel that they 
are engaged in a common cause. 

By following the progress of the movement in all parts of the 
world as recorded in the pages of Charities, or Out-Door Life, or 
some of the medical journals, or the daily press, by direct personal cor- 
respondence with those who are at work elsewhere, by becoming a 
member of the National Association and by attendance upon its meet- 
ings, one binds himself to the goodly fellowship which is engaged in 
what often seems to me the most honest and useful piece of work now 
going forward upon God's footstool. 

The specific measures for which a local association or committee 
for the prevention of tuberculosis should work, naturally vary with the 
size and the character of the community in which it is to operate. It 
is safe to suggest to all the desirability of securing the services of an 
executive secretary who need not, but sometimes may advantageously, 
be a physician, an office open at convenient hours for callers, and as 
much of a constitution or by-laws as will insure regular meetings of a 
governing body, and the fixing of responsibility for work to be done. 

If there is no special hospital for consumptives, or separate ward 
in a general hospital, that will frequently be a good objective point of 
attack. In this connection the pamphlet published by the New York 
Committee on the Prevention of Tuberculosis, entitled County and 
City Care of Consumptives, showing various methods of safe and 
economical housing will be suggestive. If there are many who are not 
receiving suitable medical oversight, and who are likely not to consent 
to removal to a hospital, it may be expedient to establish a special dis- 
pensary with both medical and nursing service or, if dispensaries al- 
ready abound, to organize in existing dispensaries classes for pulmo- 
nary tuberculosis, for the double purpose of removing these patients 
from the general waiting-rooms when they are occupied by other 
patients, and securing for the consumptives the advantage of closer 
specialization and more appropriate treatment. 



AND PREVENTION OF TUBERCULOSIS 59 

There is as yet no city of considerable size in the United States 
in which there is even an approach to adequate hospital and dispensary 
facilities for consumptives. In these two tasks alone, therefore, there 
is ample opportunity for useful service for all the associations which 
are likely to be formed in the near future. Washington, the national 
capital, until one year ago had no hospital, sanatorium, or dispensary 
for consumptives although the Home for Incurables with its limited 
resources did not refuse to receive advanced cases of pulmonary tuber- 
culosis. It is not impossible that there may be some relation between 
this lack and the fact that the city of Washington in 1900 had a death- 
rate higher than that of any other city except New Orleans, and a 
death-rate from tuberculosis higher than that of any other city except 
New Orleans and San Francisco. The pavilion at the Asylum Hospital 
opened last year accommodates thirty-four patients which is about one 
out of seventy-five of the total number of consumptives in the city. 
Baltimore with 135 hospital beds for consumptives, Boston with 250, 
Chicago with 400, St. Louis with 100, and New York with 1,000 have 
but begun to provide for the need. 

Next to the creation of hospital and dispensary facilities, possibly 
of even earlier urgency, is the necessity of educating the rank and file 
of the medical profession as to the necessity for early diagnosis, regis- 
tration, and protection from infection by all conservative and reason- 
able means. One need not go so far as one eminent physician has 
gone in declaring that on a subject like this it is infinitely easier to 
secure the co-operation of the tenement-house population, than to win 
that of the doctors. I hold that to be an unduly pessimistic view, 
though it was based on sad experience. Without going so far, it may 
still be permitted courteously to point out that if the specialists and 
the pioneers are right, the practice of a very large number of family 
physicians is wrong — wrong, that is to say, in not making sure from 
the first manifestation of the disease in any member of the family 
that rigorous prophylactic measures are taken to insure immunity for 
the others, and wrong in the failure to join heartily in securing the 
adoption of energetic educational and preventive measures. 

And next after these two great undertakings, comes the yet 
greater, and it may be we should say even more elementary under- 
taking, to which repeated reference has already been made — the cre- 
ation of a sound public opinion, midway between indifference and 
phthisiophobia, an enlightened public opinion in which every one is 



6o NATIONAL ASSOCIATION FOR THE STUDY 

frightened just enough to act sensibly, and not enough to act fooHshly; 
just enough to insure necessary pubhc appropriations and private do- 
nations, but not enough to make it difficult for a cured and educated 
consumptive to find a job; just enough to cause the railways to dis- 
infect the hangings of a sleeping car and the cushions of a day coach, 
but not enough to cause them to refuse to an indigent consumptive 
girl, on her way to a sanatorium, the charitable reduction which is 
given to other indigent persons ; just enough to cause the city to build 
a sanatorium, but not enough to induce the legislature to permit local 
prejudice to close county after county to the urgently needed sana- 
torium, except on a bribe to the county commissioners, and the town- 
ship trustees. When this happy golden mean of public opinion is to 
be found in every community, the death-rate from tuberculosis will 
diminish with a rapidity which will enable us to contemplate the speedy 
dissolution of our association for the prevention of this disease, and 
will release for the next big task the energy and the financial resources 
which for the present are imperatively demanded for this above all 
others. 

DISCUSSION ON MR. DEVINE'S PAPER 

Dr. Arnold C. Klebs, Chicago: I should like to see the paper 
and the points brought out in it printed in large letters and published 
everywhere. One thing especially I should like to see brought out in 
the paper, or brought out as the result of reading the paper, and that 
is making more definite what the various associations should do. We 
are in a tangle. We have national, state and local associations, and 
these associations cover a certain territory, but definite work should be 
assigned to each one. So far this has not been done. State associations 
should have a definite place. The local associations ought to take their 
places, and the work they do should not be duplicated by other associa- 
tions. I have understood that certain provisions were to be made to 
this end and in whatever provisions are made Mr. Devine's recommen- 
dation should be taken to heart. I heartily endorse every word that he 
has spoken. 

Mr. John M. Glenn, Baltimore: I agree with Dr. Klebs that Mr. 
Devine's paper has covered thoroughly and in a suggestive way the 
general field of tuberculosis associations, but there are one or two 
points that should be emphasized and a little more than was done in 
the paper. There are one or two things that all associations should take 



AND PREVENTION OF TUBERCULOSIS 6 1 

up for their consideration. I look at the tuberculosis problem not from 
the side of the disease, or of the patient, but from the social side, the 
elimination of it from the community and saving the community from 
its ravages. Not enough stress has been laid upon the future, and the 
benefits that would accrue to future generations by saving the next 
generations from this dread disease. The first thing all these associa- 
tions should do should be to look into the future, and secondly to look 
broadly over the situation and see that every effort is made to spread 
general education with regard to the disease throughout the community. 
Prevention of tuberculosis may be brought about in future generations 
by preventing those afflicted with it from passing it on to others. It 
seems to me that all accept the fact that tuberculosis is a house disease, a 
disease spread more in homes than elsewhere. Therefore, the first thing 
that tuberculosis associations should do is to look to the education of the 
masses of people, a task which requires patience. A great deal of ham- 
mering is necessary to make sure that whatever instructions are given 
them are properly and efficiently carried out. Again, the district nurses 
should make frequent visitations, as should those belonging to chari- 
table and other institutions, and in this way, by constant hammering and 
appealing to the average intelligence of the people, impress upon them 
what they should do and what they should not do, as now is being done 
in Baltimore. In this way the work can be pushed along and with but 
little expenditure of money. We must not be deterred by any fear of 
not being able to raise funds. Much can be done without money ; but 
if money is needed it can be raised. There seems to be a tremendous 
optimism regarding this tuberculosis campaign and I believe it is justi- 
fied. If we need money and set our minds to raise money we can 
get all that is necessary from the state or from private individuals ; per- 
sonally I believe that most of the money needed must and will come 
from private mdividuals. I think that Mr. Folks's scheme regarding the 
issuing of stock a good one. 

Education of the people in their houses and among the poor is what 
should be done. Take, for instance, a woman without support and with 
a large family ; such a person can be taught how to prevent the spread 
of the disease to her children when a member of the family, say the 
father, is afflicted. You can also accomplish a great deal by investi- 
gating the economical side of the question ; it is a money-value to the 
community to eradicate the disease. Interesting pamphlets prepared by 
the medical officers and state boards of health can demonstrate the 



62 NATIONAL ASSOCIATION FOR THE STUDY 

economic side of the question and the loss to the community in wages 
and in other ways. It certainly is worth while looking up. This is 
the strongest argument for use in trying to interest philanthropists, 
the public and the municipalities. I am sure that if we get at it we 
can readily raise the means, the sinews of war. Teach the community 
that we are accomplishing more than by any other ways we can use; 
teach the mass of the people regarding tuberculosis and then the sana- 
toria and tuberculosis hospitals will come of themselves; this is the 
more important problem that confronts us now. 

Dr. J. M. Wainwright, Scranton: The better way for me to dis- 
cuss the paper is to tell you of our experience in Scranton. Three 
years ago seven men got together and called themselves a Board of 
Directors for the Study and Care of Consumptives, the object being 
to maintain sanatoria and dispensaries, visiting nurses, etc., and to 
educate the people regarding this disease. After the first meeting we 
had Dr. Knopf of New York come to us and deliver a public lecture, 
which did a great deal in creating interest in the scheme of getting 
money to carry on the work. Next we obtained consent to have sputa 
examined by the Board of Health laboratory. Much can be done, too, 
towards obtaining legislation when the trouble is taken. When we 
first asked for what we wanted the people laughed at us and said that 
our project was a waste of time and that the Council would not pass 
anything unless there was something in it for them, etc. To show 
what can be done I will tell you what we did. We appointed a com- 
mittee and this committee took a list of the Councilmen and we decided 
that most of them could be reached through their family physicians. 
We approached the family physicians and told them that we wanted 
to obtain some medical legislation, that we wanted so much to spend 
and that we wanted it very much, and we asked the physician to do 
something for us. After two or three days, if he had not done any- 
thing, we would again approach the physician. Finally we had 52 
out of the 75 councilmen " fixed " for the scheme. The other seven 
we could not get because we did not know who their physicians were. 
The bill we wanted passed so quickly that no one had a chance to make 
any objection. Next we got money for work with our district nurses 
and dispensaries, etc. The first day we raised $6,300 and twelve days 
afterwards our system was running. Six months after that we had 
our sanatorium built, with thirty acres of land. We now have 24 beds 
in our sanatorium. We have as yet found no trouble in getting people 



AND PREVENTION OF TUBERCULOSIS 63 

to support our work and we can get as much money as we can wisely 
spend. Last June the Board of Directors collected $10,000 in one day 
for this work. 

I think it is very important that local societies of this nature should 
have the hearty cooperation of the Boards of Health, especially in 
making proper sanitary regulations and in having sanitary control. 
In Scranton we have done this work for two years, but we cannot get 
the Board of Health to do anything and, therefore, the mortality of 
the disease remains about the same. Of course, if the Board of Health 
could be induced to do anything it would be a good thing; but their 
place is now taken to a certain extent by the visiting nurses, and much 
can be done in preventing the disease by following our methods. If 
you instruct from 20 to 30 people each week you can accomplish a 
great deal. 

A number of the speakers to-day have said that the medical pro- 
fession was doing all in its power, etc., but in my experience the 
medical profession has presented a serious obstacle to the progress in 
this new movement, and another serious obstacle I find to be the 
general dispensaries and hospitals where one man is supposed to go 
over and with care as many as 40 or 50 cases in two or three hours, a 
thing absolutely incompatible with the proper diagnosis of tuberculosis. 
In Philadelphia last year there were 873 patients in one of the general 
dispensaries and in none of them was tubercular disease diagnosed, 
a thing perfectly absurd. No diagnosis of tuberculosis can be made 
with any degree of accuracy in four or five minutes ; therefore, special 
dispensaries are very necessary. 

Dr. George M. Kober, Washington : There are a few phases of 
this question that I should like to speak on. First I think it should be 
obligatory for all local associations to be in close affiliation with the 
National Associations. Any new light that is 'to be shed on this im- 
portant question should emanate from the National Association for 
the Prevention of Tuberculosis, I would also strongly suggest that 
the question of proper sewage should be considered by the local and 
state associations, a point that has not been sufficiently emphasized. 
In the communities in which many of us live the condition of the 
houses is dreadful; this has been emphasized in New York and other 
cities, and attention to house sewage will be certain to diminish tuber- 
culosis in the home. 

There is no doubt that there has been a marked decrease in the 



64 NATIONAL ASSOCIATION FOR THE STUDY 

death rate from tuberculosis within the last few years, say lo or 12, 
and this diminution in the death rate seemed to coincide with the 
general introduction of closed sewer systems. In 1865 I called atten- 
tion to the relation that existed between dampness of the soil and 
increase in the number of cases of tuberculosis, and two factors enter 
into this : first, improper water supply, and second, dampness of the 
soil. Dampness is a very important causal factor in tuberculosis. This 
is a fact we all know. It sets up catarrhal conditions which in turn 
favor the development of tuberculosis. In many communities the 
diminution in the death rate has been due to the introduction of proper 
sewers ; this has a beneficial effect in every occupation, bringing about 
purity of air by removal of dampness from the soil. One should look 
well to the homes of the people. We know that tuberculosis is most 
fatal in damp and unsanitary houses and we should look to the better- 
ment of bad conditions as they exist in the homes. All education is 
going to prove futile unless we look to the improvement of housing 
conditions. 

Mr. Christopher Easton, Newport: In considering the economic 
argument we should take up the cost to the community in dollars and 
cents ; if this be not done I fear some one will come along and tell us 
of social waste, saying that even if tuberculosis will not destroy many 
something else will in some other way. There has been much ex- 
perience given out here from personal contact with the pauper and 
criminal classes and this means everything to those thus engaged ; but 
it seems to me that there are other classes and the consumptive should 
not be placed among the paupers and criminals ; they are unemployed 
because of their inability to engage in the struggle for existence. 

Dr. J. H. Lowman, Cleveland: If Mr. Devine's paper had been 
written one year ago it then could be said that the instructions given 
therein had been followed in Cleveland, because the organization there 
has been on the lines laid down by him in his paper. Even before- 
hand there has been the application of his prophetic work. Enthu- 
siasm came to two or three and they then issued a general propa- 
ganda. Ten lectures were written for the workingmen and delivered 
for two years, and then a small league was organized, then a general 
tuberculosis dispensary, a tuberculosis charitable organization, etc., 
and about $5000 a year was spent. In the meantime we had laboratories 
for the examination of sputa, and the sanatoria and tuberculosis hos- 
pitals worked in harmony. After a few months the work was inade- 



AND PREVENTION OF TUBERCULOSIS 65 

quate to the demands, and we then called a meeting and asked fifty 
people to gather at my house to consider the question. Invitations 
were sent to every charitable organization in the city. Fifteen 
responded and an antituberculosis league was founded, made up largely 
of members from the Young Men's Christian Association, the Young 
Women's Christian Association, the labor unions, and all that had any- 
thing to do with the uplifting of the poor. Then special committees 
were formed. We advertised extensively in the press and right here 
I wish to tell you something and that is, that you can as a rule publish 
anything you wish on Monday mornings. Therefore, every Monday 
morning appeared something on tuberculosis. Many lectures were 
given and now we are in active operation. 

Dr. T, J. Jones of Hampton Roads, Va. : All the speakers thus far 
are from the northern and western states ; I therefore thought it might 
be well to hear from a southern city. When I was a citizen in New 
York City, I thought the problems in that city were the only ones the 
country had to face, but I have since discovered differently. In this 
tuberculosis convention nothing has as yet been said regarding the 
people who suffer most from this disease, that is, the colored people. 
The death rate among them is almost three times as great as among 
the whites and I appeal to you for your sympathy and your interest 
in behalf of these people. Just think of the death rate among the 
colored people, three times as great as among the whites ! Again, they 
have not the ability, education or money, to aid them in resisting the 
disease. I remember attending another convention in which this prob- 
lem was discussed, and yet not one word was said regarding the 
colored people. I do not intend this to be an adverse criticism. 
Those of us who really care for these people must face the situation. 
At the Hampton Institute we have started a movement to combat this 
dread disease, and we are organizing all over Virginia societies who 
are to take up this question of tuberculosis. We ask for the coopera- 
tion of this association and ask its assistance, especially moral and 
financial, yes, the support of every member present. 

General George M. Sternberg, Washington: I only want to say 
one word in regard to the colored people in the city of Washington. 
The death rate from tuberculosis exceeds that of any city in this 
country with one or two exceptions, and it is due to the conditions 
under which the colored population live. Take the census of the north- 
western section of Washington, where the white people live, and the 



66 NATIONAL ASSOCIATION FOR THE STUDY 

I 

death rate there will compare favorably with any city in the country 
or the world ; but where the colored people live, in the slums, in closed 
alleys, in houses unfit for human habitation, the death rate is very 
high. Thousands live in houses without sewer connections and with- 
out water in the houses, and the problem with us is how to properly 
house them and how to provide suitable sanitary requirements for 
these poor people. A movement has been made and it now is only 
a question of money. One organization was formed for the purpose 
of building sanitary houses for these people. A company recently 
formed gives a flat of three rooms, every room lighted and properly 
ventilated, with hot and cold water in the bathroom, for seven 
dollars ($7.00) per month. All we want here now is more money. 
We succeeded in raising $30,000 and building 20 houses and all are 
occupied. This building of proper homes I believe to be the fundamen- 
tal thing in combating this dread plague, and I want to place on record 
this sanitary housing company's work. We want this to be a popular 
movement in Washington. We can build these houses and run them 
and allow the colored people to raise themselves to resist this plague. 

Dr. John S. Fulton, Baltimore: This discussion, more than any 
other which I have heard during this meeting, illustrates the necessity 
of studying the minutiae of local problems, and this necessity has been 
especially apparent to me since the tuberculosis situation in the District 
of Columbia has grown prominent in the discussion. Probably no two 
places, however similarly circumstanced in geography, or in social or 
industrial conditions, can be safely compared by taking the mortality 
returns at their face value. Certainly Baltimore and Washington can 
not, for between these two cities there are very strong distinctions. A 
Washington gentleman has remarked that the tuberculosis mortality 
of Washington is 323 per 100,000, and this seems to indicate an ex- 
cessively high mortality. But the population of Washington is quite 
peculiar in several ways, and first, in the matter of race. The colored 
population of Washington is relatively large for this latitude. Several 
cities, further south, have a less proportion of negroes than has Wash- 
ington, and the negroes are in America the preeminently tuberculous 
race. The tuberculosis mortality in this country is, for whites, 173, 
and for the colored, 490 per 100,000. A city whose colored population 
is nearly 30 per cent, of the whole may therefore expect a tuberculosis 
mortality very much higher than the average for the country, which is 
187 per 100,000 for all ages and races. 



AND PREVENTION OF TUBERCULOSIS 6/ 

Next, this city of Washington differs in age distribution from all 
other cities in the United States. The fact that it is the Capital of the 
United States, will always maintain a population which will contrast 
rather than compare with other American cities. The public business 
transacted here will always keep the population numerically strong at 
the younger and middle periods of life, and numerically weak at the 
extremes of life. The population here resembles, somewhat, that of 
our new western territories, strong in vigorous manhood, not fairly 
distributed as to sex, and below Eastern standards as to marriages and 
births. The circumstances which make Washington strong in the 
matter of individual efficiency, make her conspicuously weak toward 
tuberculosis, for urban populations between 15 and 45, the life period 
in which Washington is the strongest city in the Union, may expect a 
tuberculosis mortality of 273 per 100,000. These two factors of race 
and age will therefore go far to explain if not to extinguish the alarm- 
ing contrast which seems to lie between the Washington gross mor- 
tality of 305 per 100,000 and that for the country, 187 per 100,000. 

The remarks of General Sternberg about the housing of the poor 
in Washington suggest still other inquiries, which might reveal other 
interesting relations in the local problem of tuberculosis, and might 
turn up local conditions affecting a part of the population, which has 
no doubt the special characteristics of a political city whose poor people 
differ radically in their environment from the poor of a great commer- 
cial or manufacturing city. It is doubtless proper for the Federal 
Government to inquire into the details of morbidity and mortality in 
the Federal Departments. That indeed should be done without the 
stimulus of an alarming exhibit. It is fair to doubt that the city of 
Washington has any unenviable distinction in the matter of tubercu- 
losis. These remarks are intended to show that in every locality the 
tuberculosis problem has its local features, that these can only be dis- 
covered by careful study by men on the spot, and that a careful study 
on the spot affords the only ground of detailed knowledge upon which 
a rational campaign can proceed. The generalities of a tuberculosis 
crusade are very well worked out. In the particulars of the subject are 
to be found the intimate and moving truth which can compel the in- 
terest of the people, who may be but slightly interested in the difficulties 
which they have in common with other people, but are deeply concerned 
in difficulties which seem their very own. 

Dr. Antonio Stella, New York: I wish to take this opportunity to 



68 NATIONAL ASSOCIATION FOR THE STUDY 

complete my remarks made in the first part of the meeting, and to 
make them simply in behalf of the Italian immigrants in this country. 
What I wish to emphasize is the need of some plan, such as that sug- 
gested by Mr. Devine, that is, the creation of a committee who would 
develop particular activity in effectually carrying out the plans of the 
Association. The great trouble that we encounter is the inability to 
speak the English language. The pamphlets referred to by Dr. Dar- 
lington can have but little effect. The lectures given under the aus- 
pices of the Charity Organization Society have done much good. 
While at first they were attended by some lo or 15 people, this year 
there were as many as 300 who attended these lectures in the public 
schools. It is important to state that prevalence of tuberculosis is not 
at all characteristic of the Italian race ; this is a point that is not gen- 
erally understood. It is supposed that all Italians are predisposed to 
tuberculosis, but this is a wrong impression. The prevalence of this 
disease in this country among the Italians must be explained in the 
same way that you explain it as it exists among your negro popula- 
tion, the city life and all that it implies. 

Dr. S. A. Knopf, New York: There has been a great deal said 
about the negro mortality from tuberculosis. In New York City last 
week we had our first conference with prominent citizens of the negro 
race and they admitted that before liberation from slavery the mortality 
from tuberculosis was almost nil, while now it is excessive; they ad- 
mit that it is due to the bad housing, but they also admit that it is 
due to bad living. The majority of these people keep late hours, being 
employed as waiters, hall-boys, janitors, etc., living in a very un- 
hygienic manner and thus they were themselves responsible for this 
excessive mortality from tuberculosis. I do not believe we can help 
tuberculosis in the negro race without intelligent negro help; the in- 
telligent negro himself should aid us in educating his people in regard 
to the various phases of the tuberculosis problem. 

Another speaker has to-day touched upon the education of the 
school-children. Wherever I have been called to lecture I have always 
made it a point to give them alphabetically what I have on the preven- 
tion of tuberculosis. Please bear in mind that the scrofulous and 
tuberculous child may become a consumptive adult. 

I wish to pay a tribute to the laymen of this Association. I must 
be frank with you and confess that when we started out to form this 
tuberculosis committee I had the signature of eleven prominent phy- 



AND PREVENTION OF TUBERCULOSIS 69 

sicians; but we could not form this committee until we had a lay- 
man at the head of it. This shows you that we must work hand in 
hand with the laymen, that the medical men, the laymen, the ladies of 
the Charity Organization Societies, the managers of those societies, 
and others should work together hand in hand. I do not believe there 
are any organizations, of any kind, that are more suited to take up 
this tuberculosis problem in all its phases than the Charity Organiza- 
tion Societies of the various states and cities. Tuberculosis is a dis- 
ease of the masses and requires combined action of intelligent laymen 
and trained physicians. 

Mr. Edward T. Devine, New York : I suppose an interpretation of 
the title of my paper is required. As Dr. Klebs has pointed out, it 
might be interpreted mainly as a discussion on the relative functions 
of national, state and local societies for the study and prevention of 
tuberculosis. In the first place I am a good deal of an opportunist 
at the present time and wherever a committee can find a man with 
eleven physicians' names signed to a paper, the general charity societies 
will not interpose between national, state and local bodies. I believe 
every committee should have some sort of national beginning; the 
national association should cultivate rules for the local bodies to follow 
and local organizations should receive encouragement wherever found. 
The most important function at present of the national association is 
shown in its relation to local bodies; it should gather together and 
have in one place that material which shall be the fountain for dis- 
cussion and information. There should be gathered together such in- 
formation as Dr. Sternberg has given us regarding the housing of the 
negro in the city of Washington ; also such information as Dr. Jones 
presented regarding the negro, etc. All such information should be 
gathered together by the National Association and put in such shape 
as to be useful to those who make efforts to get at it, and placed in 
the best possible channels for use by local and other bodies who need 
such information. In states with very large populations, like New 
York, Pennsylvania, Illinois, etc., there should be two or three or four 
divisions, and each division should work out its own local problem in 
its own way. Medical bodies should become united in framing sym- 
metrical laws to govern in their work, and all national, state and local 
bodies, in my judgment, should cultivate close relationship with each 
other in order to work more in harmony. 



THE PROGRESS OF THE SANATORIUM 
MOVEMENT IN AMERICA 

By William H. Baldwin 
Washington, D. C. 



A SANATORIUM IS properly a place for the treatment of patients 
who are not beyond the hope of cure; and the change in the attitude 
as to consumption is brought out by the fact that the earliest institu- 
tions listed in the admirable directory recently compiled by Miss Brandt 
for this association and the New York committee are not properly so 
called. The Channing Home, founded in Boston in 1857, the Cullis 
Consumptives' Home in 1864, and the House of Rest in New York in 
1869 were all intended to receive patients who would probably remain 
until removed by death. The purpose was humane, but not hopeful, 
and these cases marked the expected end of persons of whom con- 
sumption had once laid hold. Even earlier than these were the Lincoln 
Home started in New York in 1839 and the House of the Good Sama- 
ritan in Boston in 1861, but they were not meant for consumptives 
more than for other uncurables. 

Next came the two institutions of the Protestant Episcopal Mission 
in Philadelphia in 1876, intended especially for consumptives, which 
took patients in all stages and treated them as skilfully as possible, 
but without much hope of cure until later knowledge showed the way. 
During its existence this organization has cared for more than 3,500 
patients. 

Five years later, in 1881, the Brooklyn Home for Consumptives 
was founded, intended, as its name implies, to shelter those prevented 
by the disease from caring for themselves or being received elsewhere. 
This purpose is still carried out, though all along some of those cared 
for have left the house improved. St. Joseph's Hospital, in New York 
city, for poor consumptives was started by the Sisters of the Poor of 
St. Francis in 1882 with much the same object, and it is impossible 

70 



NAT. ASS'n for study AND PREV. OF TUBERCULOSIS 7 1 

to discover in the purpose or conduct of any institution up to that time 
any ray of hope for the consumptive, any expectation of successful 
treatment. When a so-called cold developed into what was recognized 
as the beginning of tuberculosis the patient took his chances, sustained 
himself by stimulants, exercised vigorously, avoided draughts if he 
remained in this climate and sometimes recovered if able to find refuge 
in Colorado or California, without knowing that the improvement was 
due mainly to an open-air life considered impossible at home. This 
step, however, was usually taken only as a last resort, and the hardships 
of the journey and the life there often hastened the end. Many reme- 
dies were suggested in the struggle against the disease, but they were 
without effect, like shots fired in the dark at an unseen enemy. 

The first real advance in the sanatorium movement in this coun- 
try, in fact, the first successful attack in the conflict with tuberculosis 
by modern methods, was made by Dr. Trudeau in Saranac just twenty 
years ago. Thanks to Koch the enemy had at last been revealed and 
located. There was no longer any doubt as to its identity or its manner 
of working, nor as to the difference between tuberculosis and other 
troubles which only resembled it ; but how to destroy the cause of the 
disease and restore the patient to health was the question. Some drug 
which would destroy the bacillus without harm to the patient was sought 
for, and its discovery expected ; but some of us can remember our sur- 
prise at hearing that Dr. Trudeau proposed to drive it out by life in the 
cold air of northern New York. Only the results with which his faith 
and that of his first patients were rewarded induced others to follow 
him and proved, slowly at first and then with accumulating rapidity, 
that his way was the right way, that at last a position in the conflict 
which need not be abandoned had been found. 

If Koch's discovery was the revelation of a new dispensation, this 
work of Dr. Trudeau's may be considered the first preaching here of 
the new gospel of which this association is the chief missionary society, 
a gospel, like the other, first heard with incredulity but now universally 
accepted, a proclamation of salvation to multitudes who before were 
without hope and lost. 

Interest in the subject on the part of those studying the treatment 
of the disease developed rapidly, and as they came to similar conclu- 
sions, and living witnesses from various localities proved the efficacy 
of the new treatment, other sanatoria were established, until there are, 
including those assured, 135 institutions of various kinds, new and old, 



JT. NATIONAL ASSOCIATION FOR THE STUDY 

in thirty-three states and provinces in the United States and Canada 
where tuberculous patients are cared for, of which one-third in number 
are in New York and Pennsylvania. In all there are accommodations 
for 8,400 patients, of which thirty per cent are in New York state alone. 

In the light of those who need them the situation is disheartening- ; 
but when we realize that of these sanatoria fourteen were established 
in 1902, twenty-four in 1903, and twenty-one in 1904, making as many 
in the last three years as in the seventeen which preceded after Dr. 
Trudeau's beginning, the rapid acceleration of the movement warrants 
us in regarding the next decade with hope. 

To those in charge of many of them I am indebted for information 
as to the institution and the experience in it, which I hereby thankfully 
acknowledge. It would be interesting to speak of each and its work, 
but since time does not permit they must be considered only in connec- 
tion with the main features of the movement and the general lessons to 
be drawn from the facts furnished. 

The first sanatorium to be established by a state or provincial 
association was the Muskoka Cottage Sanatorium at Gravenhurst, Ont., 
in 1897, by the National Sanitarium Association, with a capacity of 
seventy-five. This was for paying patients and the results were so 
favorable that another of similar size for people unable to pay was 
started five years later in the same place. The latter is supported in 
part by a subsidy of $1.50 per week for each patient from the provincial 
government, and is therefore quasi-provincial. 

Resembling this in its relations with the state is the Maine Sana- 
torium established by the State Association, opened six months ago. 
This has received some aid from the state, though not under state con- 
trol, and in a way takes the place of a state sanatorium. Aside from a 
few free beds patients are expected to pay what it costs to keep them. 

The first state sanatorium was established by Massachusetts at 
Rutland, fifty miles from Boston, in 1898. This is a large institution 
for early cases which had last year an average of 257 patients, and 
has been in every way successful, seventy-three per cent of the incipient 
cases discharged in the last few years having had the disease arrested 
or apparently cured. Patients are required to pay four dollars per 
week, the state making up the remainder of the cost, which last year 
was $9.36 per week. 

The next state sanatorium opened was that of New York at Ray 
Brook in the Adirondacks on July i, 1904, for incipient cases, with a 



AND PREVENTION OF TUBERCULOSIS 73 

capacity for 120. The results so far have been excellent. Admission 
is granted in the order of applications, with preference to those who 
are unable to pay and who, after being recommended by local authori- 
ties who assume the charges up to five dollars per week, are examined 
by local physicians appointed for the purpose. This system of admis- 
sion is well planned. The cost so far has been about nine dollars per 
week. 

Another opened last year is the provincial sanatorium of Nova 
Scotia at Kentville. It is beautifully located and attractive in every 
way. It has a capacity for only eighteen, but is intended as a demon- 
stration of the advantages of such institutions and will probably lead 
to larger provisions. It is supported by the provincial government. 

On seven other state sanatoria a beginning has been made. In 
Rhode Island at Pascoag the buildings have been completed and an 
appropriation made for laying out the grounds. Another bill appro- 
priating money for furnishing and for a year's maintenance, which 
had been held back until the question whether the management should 
be put into the hands of the State Board of Charities or a special com- 
mission was decided in favor of the latter, has just passed the legis- 
lature, and the institution, which will accommodate 240 and is for 
early cases, will be opened next fall. The state will assume half the 
expense of patients, and the remainder must be paid by or for them. 

In New Jersey a contract has just been let for buildings for a sana- 
torium to cost $225,000 exclusive of the equipment, to be erected by 
the first of the coming year on a tract of 600 acres of mountain land in 
the northern part of the state at Glen Gardner, purchased two years 
ago. This will accommodate 100 and is also for incipient cases. 

Contrary to expectation the Minnesota sanatorium will not be 
opened this year. With $25,000 received from the state two years ago 
the state commission bought 700 acres of land at Walker on the Great 
Northern Railroad and prepared plans for buildings to cost $100,000. 
The present legislature has only appropriated $50,000 for the purpose 
and the commission cannot make new plans and begin before next year. 
This unfortunate lack of co-ordination hinders the $75,000 from accom- 
plishing any part of its purpose, although the only sanatorium in the 
state, public or private, can accommodate but eighteen of the consump- 
tives who demand attention. 

In Ohio a commission appointed a year ago with an appropriation 
of $35,000 to provide a site and make plans, is receiving propositions 



74 NATIONAL ASSOCIATION FOR THE STUDY 

for a site and preparing the plans for beginning the buildings in ex- 
pectation of the larger appropriation by the next legislature which will 
enable it to push the work actively. 

Two years ago a bill establishing the state sanatorium recom- 
mended by a commission appointed to investigate the subject in an able 
and exhaustive report was vetoed by the governor of New Hampshire 
as a " doubtful and questionable project." Apparently he had not read 
the report. The legislature which has just adjourned appropriated 
$50,000 for the purpose, but it is not available until May i, 1907, be- 
cause there seems to be a well-defined expectation that in the meantime 
private funds to build a more ample sanatorium than this amount will 
secure will be available. In either case the sanatorium is assured. 

Missouri has just made an appropriation of $50,000 for a state 
sanatorium. 

The agitation begun in IlHnois a year ago by the state medical 
society has been systematic, diligent and effective, reaching the medical 
profession, the newspapers and eleven state organizations, and leading 
to the formation of a state society in January, which asked for an appro- 
priation of $50,000 for a state sanatorium. The bill passed the house on 
the 27th ultimo and has just passed the senate, after the amount was 
reduced to $25,000. 

In Michigan, a bill providing $50,000 to establish a state sana- 
torium is being vigorously urged by the state board of health, the state 
medical society and the medical profession generally, and is likely to 
become a law. At last accounts some days since it was in the hands of 
the Public Health Committee of the house. 

The tuberculosis commission appointed by the legislature of 1903 
to investigate conditions in Wisconsin has just made its report, setting 
forth very clearly the advantages of a state sanatorium. A bill has been 
presented to the legislature now in session asking for $90,000 for the 
erection of buildings and $25,000 as annual maintenance for them. It 
has been approved by the committee on appropriations, and, as the sen- 
timent in the legislature is strongly in favor of the movement, it will 
undoubtedly be passed, and a start made this year. 

It may be said, therefore, that in eleven states and one province 
state sanatoria are erected or their establishment assured. 

In the province of Quebec the state has given two tracts of land, 
one in the Laurentians and the other in the Lake St. John district, but 
has done nothing further. There is no provincial sanatorium in Onta- 



AND PREVENTION OF TUBERCULOSIS 75 

rio. Provision has been made by the provincial legislature for giving 
aid to the extent of $4,000 to any municipality that erects a suitable 
sanatorium in accordance with the plans approved by the provincial 
board of health and in addition to this for making a further annual 
grant of $1.50 per week per patient toward the support of the institu- 
tion. As yet no municipality has availed itself of this offer, but there 
is a movement on foot in several western counties to erect a joint sana- 
torium, and the town of Peterborough has also under consideration the 
erection of a building. This plan is a wise one because it retains the 
feature of self-government while affording encouragement by the 
province, but as yet seems to be somewhat in advance of public opinion. 
In the other three provinces of Canada efforts in the direction of a sana- 
torium have so far failed. 

As to the situation in other states, it may be said that while Con- 
necticut has no state sanatorium, it gave $25,000 toward the equipment 
of the Gay lord Farm Sanatorium which cost about $100,000, the re- 
mainder being raised by private subscription, and has given $5,000 a 
year toward its support for two years. This institution was opened last 
year and the cost so far is about eleven dollars per week per patient, 
although the charges to patients are only seven dollars per week. This 
arrangement is apparently the result of an agitation started four years 
ago for a state sanatorium. 

In the District of Columbia the request made at each of the last two 
sessions for an appropriation to start a sanatorium was rejected. Ex- 
cept for the Washington Hospital, at which the facilities have within 
the last year been supplemented by the gift of four tents from individ- 
uals, there is no place in this city of 300,000 where one who has con- 
sumption can find shelter or care. It is to be hoped that the next 
request will not be refused by those who should realize that the con- 
ditions at the national capital make such an instittition a necessity rather 
than a luxury. If this meeting of the National Association so stirs the 
hearts of its members throughout the various states that they will in- 
fluence their representatives in congress to favor the measure at the 
next session, the meeting will not have been in vain. 

In accordance with a resolution passed by the Indiana legislature 
which adjourned March 7, last, a commission to investigate and report 
to the next legislature as to a state sanatorium has just been appointed, 
with the secretary of the state association as medical member. The 
governor and others are much interested. 



J^ NATIONAL ASSOCIATION FOR THE STUDY 

In Kansas a resolution asking for the appointment of a tuber- 
culosis commission to investigate the desirability and cost of erecting a 
state sanatorium passed the house but failed in the senate, so the matter 
has gone over. 

The commission appointed in Maryland in 1902 to investigate the 
general facts in relation to tuberculosis in the state was reappointed 
last fall to continue its study and also to report in 1906 as to the 
" construction, cost, equipment, maintenance and location of a sana- 
torium for the treatment of tuberculosis." This indicates intelligent 
and steady progress in Maryland. 

In Montana, as in Kansas, the legislature failed to pass a similar 
bill and nothing is being done. There is some hope that private means 
will found a sanatorium, as there is no such institution in the state. 

A bill appointing a commission consisting of two physicians and 
the commissioner of forestry to build two state sanatoria in Pennsyl- 
vania and making an initial appropriation of $300,000 therefor was 
recently vetoed by Governor Pennypacker, not because of any objection 
to such institutions for the state but because the bill was loosely drawn 
and opened the way for abuses. Did time permit, it would be interesting 
to point out defects which justified the veto in order to avoid like faults 
in any efforts made elsewhere. Lack of clear thinking and of prudent 
demands resulting in reverses like this hurts our common cause. 

The governor hints that a well-considered bill may be presented 
by the health department created by this same legislature, which also 
appropriated $40,000 for buildings and $60,000 for maintenance for the 
White Haven Sanatorium, besides amounts for other like institutions. 

The commission appointed two years ago in Vermont made a re- 
port last summer recommending an appropriation of $50,000 for a state 
sanatorium, but I cannot learn that anything further has been done. 

In Washington a bill, making provisions for a site and for pre- 
paring plans for the erection of a state sanatorium, was introduced in 
the last legislature, but was crowded out in the closing days of the 
session. There was no opposition and as the state board of health is 
very much in favor of the project and is looking up the facts to present 
with a definite plan to the next legislature, it is to be hoped that no time 
has been actually lost by the failure of the bill. 

In Arizona nothing has been done although there are a great num- 
"ber of tuberculous people scattered throughout the territory who have 
gone there on account of the climate, and a sanatorium is much needed 



AND PREVENTION OF TUBERCULOSIS ^^ 

to care for them, both resident and non-resident, and teach them and 
others the dangers of the disease. The territorial health officer is 
alive to the necessity of such an institution and hopes the discussion 
of the subject in this meeting will help towards it. 

In Kentucky a committee has been appointed to bring the matter 
before the legislature which meets next year, and if the proposed new 
capital does not absorb all the available funds of the state, some action 
may be taken. 

Although there are no tenements in North Dakota the Scandina- 
vians and others who live in small and poorly-ventilated houses have 
consumption badly. Provision is needed for them, but nothing has yet 
been done. In South Dakota the disease is very prevalent among the 
Indians, and some pathetic accounts are given of their struggles with it. 
It is said that the Sissitons, peaceful, reliable citizens, living on lands 
taken in severalty, are likely to be exterminated by consumption. It is 
the intention to bring the matter to congress at its next session, but 
no steps have been taken towards a state sanatorium. 

In Texas the subject was brought before the legislature which has 
just adjourned but nothing was done. In Virginia and West Virginia 
also bills introduced several years since failed and no efforts are being 
made at present. The recent California legislature passed a bill appro- 
priating $150,000 for a state sanatorium, but the governor vetoed it. 

Arkansas, Georgia, Idaho, Mississippi, Nevada, New Mexico, 
North Carolina and Oregon report that nothing is now being done for 
a state sanatorium, and failure to furnish any information indicates 
that nothing has been accomplished in the remaining states. 

In 1898 Surgeon-General Wyman took up the question of a sana- 
torium for tuberculous seamen, and after various locations had been 
investigated the old military reservation at Fort Stanton, N. M., was 
turned over to the Marine Hospital Service ih 1899 for the purpose. 
The reservation contains thirty-eight square miles, most of it under 
fence, and the accommodations can be indefinitely extended by adding 
tents. Much of the food required is raised on the land, making the 
administration most economical besides affording occupation for such 
patients as can help in the work. The cost of the average ration for 
1902 was but thirty cents per day per man. The most rigid care is 
exercised as to infection and results have been excellent; though as 
only fourteen per cent of patients discharged last year were first stage 
cases the percentage of those cured or improved was under sixty. 



78 NATIONAL ASSOCIATION FOR THE STUDY 

There are at present about two hundred under treatment. If it 
were possible to allow civilians to take advantage of the opportunities 
of the place under proper regulations to protect the interests of the gov- 
ernment, the favorable conditions and the economy of subsistence 
while there might more than offset the expense of sending many cases 
out. 

In 1899, also, Surgeon-General Sternberg established a United 
States General Hospital for tuberculous soldiers of the United States 
Army at Fort Bayard in New Mexico, the most favorable location for 
treatment he could find. The results have been very favorable, from 
ninety to ninety-five per cent of cases of the first class having been 
cured or improved, and from forty to fifty-five per cent of third-class 
cases. Soldiers may be sent there directly by the commandant of any 
army post on a surgeon's certificate. Some civilians are admitted at a 
moderate charge on authority of the War Department but these are very 
few. There were at the end of last year about two hundred and fifty 
under treatment. 

The Navy has not yet established a sanatorium, but since December 
1903, has been experimenting with a camp at the naval hospital at Pen- 
sacola, Florida, accommodating fifty in tents, and has eight officers 
and sixty-four enlisted men in the army sanatorium at Fort Bayard. 
The results have been most favorable, leading to studies of sites and 
plans for a naval sanatorium which will no doubt result in definite 
action on one ere long. 

A commission of the National Fraternal Association, with a vast 
membership back of them, visited New Mexico two months ago to 
select a site for a large sanatorium for its members, and has just secured 
the Montezuma hotel and springs with 11,000 acres of land at Las 
Vegas, to be perpetually maintained as a sanatorium. 

As to municipal sanatoria, the first one established was the Branch 
Hospital at Cincinnati, O., in 1897, located just outside the city and 
accommodating 125, free to residents of the city. 

Next came the Tuberculosis Infirmary of the Metropolitan Hos- 
pital of New York city on Blackwell's Island, established by the presi- 
dent of this section when he became Commissioner of Public Charities 
in 1902. This was one of the most important steps taken in the forward 
movement, and demonstrated that by improving opportunities not 
entirely favorable, and doing earnestly what is possible according to 
the best knowledge on the subject, much may be accomplished. The 



AND PREVENTION OF TUBERCULOSIS 79 

practical results obtained with patients coming from the most unfavor- 
able conditions are remarkable, and show that officials in any city, who 
are charged with the care of the masses who most readily fall victims 
to consumption, are not excused from making provisions for them on 
account of poor climate or the lack of funds to erect expensive build- 
ings. For measuring up so promptly to this opportunity, our chairman 
deserves the hearty thanks of all who are interested in this cause. 

Another municipal institution worthy of notice is the Riverside 
Sanatorium established in the following year by New York city on 
North Brother Island to which section 139 of the New York sanitary 
code permits the forcible removable of any consumptive, who, by re- 
fusing to comply with the regulations of the Health Department, is 
endangering the health of those around him. Every city should have 
such a provision. 

In 1903, also, provision was made in the Emergency City Hospital 
of St. Louis, Mo., for tuberculous patients, and the Tuberculosis Sana- 
torium of the city hospital of Cleveland, O., was started in an old 
building within the city limits, previously used for another purpose. 
Persistent and well-directed efforts in Cleveland have increased the in- 
terest in the subject to such an extent that six months ago the city 
bought thirteen hundred acres of land ten miles out, beautifully lo- 
cated, with rolling ground, woods, springs, and fine views, where a 
tuberculosis sanatorium, on the plans for which the architect is already 
at work, accommodating 200 patients and taking both chronic and re- 
cent cases, will be erected. 

Special provision was made for the treatment of consumptive in- 
mates at the State Almshouse in Rhode Island in 1896. This example 
has been followed since in the State Hospital at Tewkesbury, Mass., 
the Boston Almshouse, the Erie County Poor Farm at Buffalo, N. Y., 
Wayne County House at Eloise, Mich., and the Westchester County 
Hospital at East View, N. Y. ; and the subject is under discussion in 
various other counties. Accommodations in prisons and insane asylums 
are for special classes of tuberculous patients, not here considered. 

Mention should also be made of the Henry Phipps Institute in 
Philadelphia for the study and prevention of tuberculosis, in which 
only people who are unable to pay and whose cases are considered hope- 
less are received. The most careful records possible are being taken of 
each case, and the studies made by a corps of physicians under the direc- 
tion of Dr. Flick will prove invaluable. The establishment of such an 



8o NATIONAL ASSOCIATION FOR THE STUDY 

institution on this plan, by the gentleman who is furnishing all the funds 
which are necessary, is one of the greatest steps which has been taken 
in the forward movement against this scourge. 

Although some children are admitted to several of the sanatoria 
and hospitals with other tuberculous patients, nothing whatever was 
done to provide those suffering from tuberculosis of the joints and 
similar forms of it with the seaside treatment which has done so much 
for thousands of children in the large institutions by the sea in France 
until the New York Association for Improving the Condition of the 
Poor demonstrated the advantage of such treatment in its tent camp 
at Sea Breeze in the year which has just closed. The results were 
wonderful, and show clearly that the matter should be taken up in a 
large way at once, preferably, in the opinion of Dr. Linsly R. Williams, 
by establishing a sanatorium by the sea under municipal control. 

Dr. Menard says every large city should have such accommoda- 
tions for a thousand children for each million inhabitants, which would 
mean 3,500 beds for New York. There is no part of the field to-day 
where the issue is more sharply drawn between the suffering and pain 
of helplessness and deformity projected by neglect into lives just begin- 
ning, or happiness and usefulness made possible through all the coming 
years by even slight attention now. The cry of the children should 
also arouse us to the danger from tuberculous people in any home where 
they are found. 

All this experience with sanatoria for tuberculosis has demon- 
strated certain things : 

I. Climate is not an essential, or even the most important, factor 
in its treatment. What was once said of whiskey applies to air — 
" Some may be better than others, but none of it is poor." While it is 
easier to lead an open-air life in a dry, clear climate and general con- 
ditions there may be more favorable, almost as good results can be 
obtained with proper care in locations in almost any state ; and the dif- 
ference does not make up for the lack of those advantages which only 
care in a sanatorium can give. From California, Arizona and New 
Mexico comes a humane protest against longer setting consumptives 
adrift with slender resources or none to fight the disease among stran- 
gers. Dr. Norman Bridge, who has had unusual opportunities of obser- 
vation and who yields to no one in his praise of California air, declares 
that he would rather have a patient kept under proper conditions in an 
eastern city than send him to some better climate to shift for himself. 



AND PREVENTION OF TUBERCULOSIS 8l 

From his experience at Fort Bayard Dr. Bullock thinks that, other 
things being equal, the results there are about ten per cent better than in 
the East, but more than this is often lost by advanced cases in the jour- 
ney out. 

2. Fresh air, rest and nourishing food in abundance are necessary, 
and the patient must be faithful and regular in all his habits in regard 
to them. It is practically impossible for him to be so outside of a 
sanatorium. The fight is a long one, in which carelessness of one day 
may undo all the benefits of faithfulness of the preceding thirty days. 
Careful directions may be given, but it is asking too much of a man 
weakened by disease to take all the care which the healthy people about 
him, by whose standard he measures himself, disregard. After some 
years' experience with hundreds of employees, a successful rolling- 
mill superintendent said, " When you tell a man to do a thing you are 
just half done ; the next thing is to see that he does it." This is even 
more true of directions given to consumptives; and while the sana- 
torium is only one part of the armament in this struggle, it will be 
impossible to make reasonable progress without the care which it alone 
can properly give. 

3. In a sanatorium medical superintendence is the most essential 
feature. The sanatoria in this country and abroad which have accom- 
plished most have been directed by men of force and intelligence, who 
were in love with their work. Some one said that Mark Hopkins at one 
end of a log in the woods and a student with a book at the other made 
a college. A doctor, whom we know, with one patient in a shanty in a 
pine forest makes a sanatorium which is bound to grow ; and it is for- 
tunate that his example and the possibilities of helping mankind in this 
movement are raising up other men to follow the same methods. 

Assuming, then, that the numerous cases of tuberculosis can best 
be handled in sanatoria, how shall the problem 6f caring for the hope- 
ful and hopeless cases be solved, and for which class is it most necessary 
to make provision? Another natural division of each class may be 
made between the well-to-do and those who have small means or none 
at all. Those in the latter class are far more numerous, and as the 
former are able to find places in some of the sanatoria already estab- 
lished, whether near or far away, we need consider here only those 
who are unable to take advantage of existing institutions, and others 
which the demand for them will create, in this way. 

The fact that a case is hopeless seems to warrant us in giving our 



82 NATIONAL ASSOCIATION FOR THE STUDY 

first attention to others who may recover, but the danger of still fur- 
ther infection from the dying consumptive, if not properly cared for, 
is so great that if we are ever to overtake the disease it is necessary to 
care for the advanced as well as for the incipient cases. 

The task is one which belongs to society as a whole, not only on 
grounds of humanity but of self-preservation and social economy. In 
approaching it it seems clear that each state ought to do its part by 
providing at least one sanatorium for incipient cases. The political 
units by which the poor are now cared for are too small to build and 
properly maintain establishments for the purpose in the present state 
of knowledge on the subject, and it would be impossible to find a 
proper location for such a sanatorium in each, though it may be found 
in the larger choice which every state affords. The public welfare 
demands that the state shall make provision for tuberculous patients 
just as it does for the insane, the epileptic or others who require a care 
for which counties and towns cannot properly arrange. The objection 
made by Governor Pennypacker to the Pennsylvania bill that it opened 
the door for the care by the state of smallpox, bubonic plague and 
other dangerous diseases is the only one not well taken; for all other 
contagious diseases reach a crisis promptly while consumption demands 
long-continued care and support if the danger to the community is to 
be avoided. 

Furthermore, such a sanatorium is an educational institution 
which the state has the same right to establish as to found a state uni- 
versity or an agricultural experiment station. The knowledge there 
obtained is a benefit to the citizens of the whole state. People are now 
infected by consumption through ignorance on the part of those who 
give and those who receive the infection. Each man whose habits have 
been corrected by even a short residence in a sanatorium will neither do 
nor willingly permit to be done by others acts which before would have 
seemed perfectly natural. In no more effectual way can the sanitary 
knowledge necessary for controlling tuberculosis be disseminated, and 
this educational duty is a perfectly proper one for the state to assume. 

It is quite proper that the state, having provided a sanatorium, 
should not be asked to bear the expense or all the expenses of support- 
ing the people in it. As in Massachusetts and New York, the patients 
who are able should pay at least part of the cost of maintenance, and 
if they are not able the local authorities in the place from which they 
come may pay it for them. 



AND PREVENTION OF TUBERCULOSIS 83 

Large cities also should provide sanatoria for hopeful cases among 
their citizens. As a rule, it is hardly possible to find pure air and 
suitable surroundings within the city limits, and the institution should 
therefore be outside. If properly conducted, experience shows, as in 
the case of Rutland, that there is absolutely no danger to any commu- 
nity from the proximity of such a sanatorium. The state should, there- 
fore, interpose no obstacle to the location of such a municipal sana- 
torium in the surrounding country, under proper supervision, and the 
relations between the state and its large cities in this respect should be 
entirely harmonious. It cannot be forgotten that the establishment of 
the New York city sanatorium, so urgently needed, was prevented by 
the passage of the Goodsell-Bedell bill. One or more locations can 
now be secured, but the law still delays the execution of this most im- 
portant project by obstructing the purchase of the one best adapted 
for the purpose. 

If a beginning is made by the establishment of a sanatorium for 
incipient cases by each state and each large city, the advantage of such 
institutions will be so clearly demonstrated that local authorities will 
be likely to make any further provision which is needed if they are at 
all able. If they are not, the need should still be supplied by the state. 

In the absence of prompt action by the state it is to be hoped that 
many local authorities will make a beginning in a modest way from 
some such constructions as the lean-to at the Loomis sanatorium, the 
Blackwell's Island tents or others similar to those suggested in the 
pamphlet on County and City Care of Consumptives, zvith Some Meth- 
ods of Housing, recently published by the New York committee. 

An advantageous location for a sanatorium or hospital for the 
treatment of presumably hopeless cases is not so necessary, and the 
care of such people who are financially unable to provide for them- 
selves properly devolves upon the authorities who now have the care 
of the dependent poor. For the sake of others whose health may be 
endangered by them as well as for the chance of recovery which intel- 
ligent treatment by modern methods holds out to many consumptives 
formerly considered hopeless, the city or county is warranted in pro- 
viding and properly maintaining an institution for advanced cases of 
tuberculosis. The best location possible near the city, or, for a county 
within the county, should be secured, and it should not be connected 
with the almshouse. People who are made poor by this disease, for 
which they are not responsible, should not be classed with paupers, nor, 



84 NATIONAL ASSOCIATION FOR THE STUDY 

if they recover, should their weakness be made worse by the feeling 
that they have been in the almshouse. Any extra cost to the com- 
munity of suitable care and treatment of poor consumptives in such a 
separate institution is justified from an economic standpoint by the 
removal of sources of infection, which are certain to involve far greater 
expense, to say nothing of the suffering connected with it. Since the 
proper conduct of such institutions depends rather upon faithful care 
than upon special medical skill, it seems to belong in the department 
of charities rather than the health department, but the two should work 
in harmony in order to secure the best results for those who are sick. 

By such a general division of the field provision will be made for 
all cases not otherwise taken care of ; but this should not shut out those 
benevolent institutions which are now doing so much for sufferers from 
tuberculosis. These deserve the continued and generous support of the 
public, and so far as they can solve the problem the work is likely to be 
better done because done from the love of it than if left to the state. 

So far as any institution depends upon the public it is important 
that those who sustain it should be fully informed as to the way in 
which the money is spent and the results which it accomplishes. For 
this reason, and because proper comparison both of the results of treat- 
ment and the cost of maintenance in sanatoria throughout the country 
will be of great advantage, some simple and yet adequate system of 
sanatorium reports and accounts might be adopted. The excellence of 
the object will not excuse any lack of care in business management. 
The task before us is so great that no resources should be wasted. The 
sunlight of publicity on all details will be helpful. I remember the 
peculiar pleasure it gave me to learn that the cost of eggs, milk and 
laundry and other such items per patient per week for the White Haven 
sanatorium had been carefully figured out; and I believe the systems 
carried out there and at the Henry Phipps Institute have not only aided 
in the successful management of those institutions but have gone far 
toward attracting the support which they have received. Such methods 
are a protection both to the donor and the manager himself against 
carelessness in supervision and the man who gives money is encouraged 
to give more if he can see at a glance just how it has been spent. 

The present system of uniform reports and accounting has done 
much for the railroads of the country and this association can help the 
sanatoria which we so much need by devising and recommending a 
suitable and uniform system for them. 



AND PREVENTION OF TUBERCULOSIS 85 

Although the disease may in many cases be arrested by a compara- 
tively short stay in a sanatorium, a complete cure requires a long time. 
If the patient returns too soon to his former surroundings and resumes 
his occupation, the old influences are likely to cause a recurrence of 
the trouble. How to prevent this is the most perplexing question in the 
treatment of tuberculosis. A man who was asked what he did during 
the French Revolution replied, " I lived." If those who have consump- 
tion were financially able and could be content to do little more until 
the cure is complete, time would be saved. 

Various efforts have been made to find some occupation by which 
those able to leave the sanatorium could earn a living without inter- 
fering with the completion of the cure, but with no general success. 
At Saranac instruction in bookbinding and decorating fits some to earn 
a little. In the case of some sanatoria the locality affords light work 
of various kinds for those who leave, but in others there is none. If 
there is a large farm connected with the institution patients can, under 
the careful direction of the physician, as they become stronger, accus- 
tom themselves to an increased amount of outdoor farm work which 
helps to reduce the cost of the institution ; and in some cases a modest 
subsistence can be gained in this way after leaving the institution. A 
noteworthy instance of the benefit of such work is furnished by the 
experience at Wynne State Farm in Texas, where the inmates of the 
Texas prisons were put to work to their physical advantage and the 
financial profit of the state. At the Association Health Farm in Den- 
ver the problem is being worked out in this way, and at the Muskoka 
Free Hospital a poultry-raising project has been found suitable and 
profitable. It has been suggested that this association might maintain 
an information bureau to aid in furnishing such employment. 

In the rushing life of this country, however, the man who is not 
fully equipped for whatever work offers is badly hindered in obtaining 
any, and this phase of the problem merits our most serious considera- 
tion. 

DISCUSSION ON MR. BALDWIN'S PAPER 

Dr, W, J. Marcley, Rutland, Mass. : The question of the em- 
ployment of the improved cases is a very difficult one. A patient about 
to leave the sanatorium may be classed as able to work after a period 
of treatment, or as unable to work. If I may quote from the figures 



86 NATIONAL ASSOCIATION FOR THE STUDY 

we have at our sanatorium, I would like to say that we have there a 
record of the people who are discharged able to work for from 3>4 to 
5/^ years. We find that 80% of these cases who are prepared to work 
do so and are still working at their old occupation or other similar 
pursuit. What the future will be we cannot say, but it brings us to a 
recognition of the fact that the duty of the sanatorium does not termi- 
nate with the discharge of the patient. The whole tuberculous problem 
has for its guide education and it is easy to educate the patient. We 
can teach him to lead a clean life and thus have perhaps twelve hours 
out of the twenty-four under his own control. He can care for himself 
and be temperate in his habits. We sanatorium men should try to in- 
fluence the owner of the building and the employer of the consumptive, 
but I cannot say how this should be done. Every institution should 
maintain a public officer, preferably a physician who should spend two 
thirds of his time in visiting various parts of the Commonwealth, as- 
sociating with the officers of the State Board of Health and have 
authority to enter factories and stores. No benefit can be derived as 
great as the education of the people in various societies. In some 
states there are societies for the study of tuberculosis and they should 
follow the cases discharged from the State Institution; they should 
follow their method of living and working. One of the best signs of 
the times is the interest that is being manifested in the tuberculous 
problem on the part of the labor unions. No doubt these unions 
properly supervised and directed by their various physicians will be 
able to bring about a much better condition and improve the things 
that make for the continuation of health for the consumptives. 

Dr. J. N. Hurty, Indianapolis: Dr. Baldwin has so thoroughly 
covered almost every point that I do not think I have much to add. 
Of course we regard this movement as educational more than anything 
else. It is obviously impossible for the people to take hold of the 
subject of the combat against tuberculosis and produce any great result 
except in an educational way, and we must therefore regard the sana- 
torium as an educational institution. If in the curing of a large per- 
centage of the inmates we do not carefully teach them the science of 
.prevention and also impose upon them most thoroughly the necessity 
of teaching others and showing by example what can be done to 
prevent this terrible disease, one of the foremost objects of the sana- 
torium will be missed. In Indianapolis we have a municipal sana- 
torium with 21 beds in which we receive both the curable and incurable 



AND PREVENTION OF TUBERCULOSIS 87 

and there is a small institution in Fort Wayne. Our last legislature 
agreed to appoint a commission to investigate the subject as other 
States have done. The Chairman and Secretary of that Commission 
are present here at this meeting under the direction of our Governor. 
The Indiana State Board of Health has been working along these lines 
for 7 or 8 years, the work being entirely educational. Lectures before 
institutions and before women's societies or wherever a hearing could 
be secured, including even the high schools, should be delivered. This 
subject is now being taught to the students in some places and we feel 
that probably it is most fertile ground to cultivate. The minds of the 
students are open for instruction and to prepare their minds just as 
they are ready to leave the high school we deem a most important duty. 
We have at last found a philanthropist who has not yet made public 
his offer, but I am permitted to state that it will be made. A private 
sanatorium will be started very soon and $50,000 will be given at once. 
He is taken with the idea of the Sharon Sanatorium and proposes to 
treat only young women. Being an exceedingly practical man he gave 
me some excellent suggestions, among others the cleaning of premises. 
Of course we have a law requiring people to keep their premises clean, 
and if they do not do it the city does it and it is charged against the 
premises. Why not tax the unsanitary places, factories, stores, and 
places of all kinds and devise some scheme to enforce this tax and 
explain that they are producing the disease? If a man owns unsanitary 
buildings, let him be taxed heavily. This is not impracticable, but the 
taxation must be uniform. 

Mr. Paul Kennaday, New York : It is too soon for me to give you 
much of an idea of our methods in endeavoring to secure work for 
improved consumptives, as we are completely at sea and do not know 
just what lines to adopt. It is a most difficult question and has been 
largely neglected. At present we have a paid investigator in the field, 
whom we send to the country after we have first selected a favorable 
region. He then settles down and gets into friendly relations with the 
farmers, finding out what the demand for labor is. From time to time 
he reports to the committee and is put in touch with individual con- 
sumptives who are ready to be discharged from the state hospitals or 
who have been under observation elsewhere. He travels back to the 
farm and tries the place to see if the patient has the ability to do the 
work. This work has only just begun, and we cannot tell as yet what 
the results will be. 



88 NATIONAL ASSOCIATION FOR THE STUDY 

Mr. W. H. Allen, New York : The seaside camp is but an experi- 
ment. As to the importance of attracting the attention of philanthro- 
pists and hospitals to the scheme, many could speak. The important 
point is to convince the adult consumptive of his relation to the de- 
formed children. We must all have been impressed in Mr. Baldwin's 
remarks by the difference in his tone and the difference in our re- 
sponsibilities when he spoke of the crying child. By aiming to attack 
this problem from the standpoint of the crying child we have a tre- 
mendous advantage. By calling the attention of everybody to the child 
and by using the child as an illustration, we can inspire that public 
enlightenment of which Dr. Osier spoke. If you say to a man in the 
street car, " That man opposite is a consumptive," he will say that 
the man should not be allowed to ride. If you say a hunchback is 
due to the germ of tuberculosis, a man will say we must do something 
for this. Look at the picture in the circular that is being passed 
around; watch the child's expression. If we could, through this ex- 
periment, get everybody interested throughout the country to say, 
whenever a deformed child is seen, that the chances are lo to i that 
the child's deformity is due to some adult consumptive's neglect or 
to society's neglect, it seems to me we could get the interest, and the 
sustained interest that is exceedingly difficult so long as we talk about 
the adults. We feel that we have accomplished considerable this 
winter. We have not been able to do enough work. Of 63 children 
who came to us the parents of not one had ever been told by their 
physicians that the disease was due to the germ of tuberculosis. The 
parents must be told that it is due to tuberculosis. 

Dr. Charlton Wallace, New York: As to the character of our 
cases, all are admitted irrespective of the condition of their lesions. 
We have taken the most hopeless cases we could find. When we 
started the hospitals only let us take those cases which they could not 
treat successfully. We lay stress on three important points ; ( i ) Salt 
air, proper food and immobilized joints; (2) Mental considerations; 
teaching the children. The Board of Education supplies two teachers 
and the children are in school 2 or 3 hours daily; (3) The moral 
aspect; keeping them in such surroundings that they do not know 
they are sick. We keep them in the fresh air; the day they arrive 
they go outdoors. No child ever complains of being cold. You might 
say the seashore is bad on account of the changeableness of the weather, 
but there have been only two days when the children have not been 



AND PREVENTION OF TUBERCULOSIS 89 

out of doors all the time. We must accept the previous experience of 
European surgeons on this subject and did so before we erected our 
tent on the seashore at Coney Island. The experiment is under the 
observation of four surgeons and they are all unanimous in the ex- 
pression of their opinions. There are thousands of crippled children 
suffering from tuberculous bone lesions. How much better if they 
could be made self-supporting and self-sustaining! 

Dr. T. E. Oertel, Augusta, Ga. : We have done nothing in the 
South. In Georgia we are in training for a fight and we are going to 
win it. There is just one little point that I think may possibly be of 
some value and help. There are some here who are going back to 
States where there are no State sanatoria. Our State Society ap- 
pointed a committee of five to investigate this subject with myself 
as Chairman. We asked for power to do several things; (i) go to 
the legislature and ask for funds; (2) go before the legislature rela- 
tive to the subject of a State sanatorium, and (3) add to our committee 
one member from each county in the State. These requests were 
granted, and as soon as I get home I shall mail letters to various 
men who have been selected in each county in the State. The object 
is twofold: (i) to form within the State Medical Society an anti- 
tuberculosis league, and (2) to make a big stick with which to hit the 
representatives of the legislature. When we go before the legislature 
we must meet politics; reason does not prevail with politics. I shall 
write not one letter but all the letters that seem necessary when I re- 
turn, urging every man to see his representative; also to see every 
man in his county and urge him to do the same thing. If they are 
instructed by their constituents they must and will do it, but other- 
wise they will not. The medical profession, organized as it now is, 
has it well within its powers to compel the legislature to do this and 
it remains to be seen what can be done along these lines. If Lincoln's 
old motto, " keep pegging away," will do it it will be done. 

Dr. J. M. Wainwright, Scranton: A gentleman in Oil City re- 
cently bought a few tents and fitted them out so that they will ac- 
commodate 16 consumptive patients. He did the whole thing at his 
own expense and feeds them at his own farmhouse. I believe this 
work is entirely unique in the United States but it would be well worth 
while for charities to look it up as well as the authorities. It is im- 
portant as it shows what can very easily be done in a very small town. 
Any one of you can get a couple of hundred dollars and put a few 



90 NATIONAL ASSOCIATION FOR THE STUDY 

consumptives out on a farm for the summer. Next summer you will 
have all the money you want. 

The Chairman having called on Mrs. J. E. Newcomb, of New 
York, to make a few remarks regarding Stony Wold Sanatorium, and 
she not caring to discuss her work along this line, further details of it 
were given by 

Dr. S. A. Knopf, New York: These ladies are doing this work 
alone; it should be imitated. Mrs. Newcomb asks us to go to such 
and such a house and there we find a number of ladies, who discuss 
with us their experience with consumptives. There is no more grati- 
fying field than that these ladies have mapped out for themselves. 
You should see how enthusiastic they are in their work. They have 
several auxiliaries and they care for the poor consumptive working- 
girls and women. I wish you could see how these girls are taken 
care of and you should see some of the cures coming back. 

Dr. Geo. M. Sternberg, Washington, D. C. : Our pride would 
perhaps induce us to say nothing. Some of us have been working 
away, but the results are very meagre. Mr. Phipps of Pittsburg has 
established a dispensary here in Washington, and we are getting con- 
tributions from our citizens and these have enabled us to carry on the 
work to date. We have no hospital or sanatorium for our consump- 
tive cases. There are a few cases over at the Municipal Hospital and 
we have tent accommodations for about 25 or 30. We have failed 
so far to obtain any appropriation from Congress for a tuberculosis 
hospital although we have represented the matter as strongly as we 
knew how, but without success. We are hoping that something may 
be accomplished hereafter. While I was connected with the Soldiers' 
Home I started a hospital for consumptives at Fort Bayard. We had 
from 900 to 1000 soldiers at the Home, many of whom were invalids 
and many others were tuberculous, and they were allowed to wander 
around the ground and expectorate wherever they pleased. A whole 
herd of cattle was killed because they became tuberculous, possibly 
contracting it from the tubercular soldiers. Now any man who con- 
tracts consumption in the army is at once sent to Fort Bayard and 
the results of this effort have been published. There is one point of 
importance and that is you must not compare our army results with 
those obtained at the Massachusetts Hospital, as they are selected 
and early cases while ours are in men in advanced stages. 

Mr. Edward T. Devine, New York: It is only fair to point out 



AND PREVENTION OF TUBERCULOSIS 9 1 

that we cannot expect that there will be very generous or vigorous 
response to our pleas for assistance unless there is also an entire 
willingness on the part of the people and citizens of Washington. 
When the suggestion was made yesterday that a congressional com- 
mittee should be appointed, and when that resolution was withdrawn 
because of the opposition of the local Health Officer, two incon- 
sistent positions were taken. We cannot at the same time expect 
that there will be a very general response on the part of the local 
authorities in the absence of the willingness of the people. 

Dr. G. M. Kober, Washington: I heartily endorse all that has 
been said by Mr. Devine. The resolution would have gone far to 
strengthen the hand of the Health Officer. We have labored for 5 
years to bring about the condemnation of houses in Washington that 
are not fit for habitation, but the objection on the part of one Senator 
prevented its becoming a law. It was simply a case of personal pique ; 
he did not want the Health Officers to do their duty. 



INFECTION IN TRANSPORTATION 

By H. M. Bracken, M. D. 
Minneapolis 



In discussing the subject it can safely be said, I think, that there 
should be no danger of possible tubercular infection while traveling in 
public conveyances. For tubercular infection there must, as a rule, be 
prolonged exposure and this should never occur in any public convey- 
ance. In the street cars one spends but a short time on any single trip. 
In the suburban trolleys the crowded condition in the cars and the 
longer trips make the possible exposures more pronounced than in the 
city cars. In the day coaches of railway trains one is not in close con- 
tact with other individuals and even should a tubercular patient be 
sitting near by, the tubercular bacilli expelled in the act of coughing 
are in a moist state and not in condition for general distribution until 
the sputum becomes dry. In sleeping-cars and on steamers one is even 
more isolated than in the day railway coaches, and the danger of pos- 
sible tubercular infection should be still less. 

In speaking thus of possible infection during transportation we 
are assuming that all public conveyances and their furnishings are kept 
well cleaned. If such is not the case there may be danger in every 
street car, railway coach and steamer berth. If tubercular patients de- 
posit infected sputum in public conveyances and it is allowed to become 
dry, it may then be a source of danger. The greatest danger from lack 
of cleanliness is undoubtedly to be found in the sleeping-cars and 
steamer berths where one may be in contact with infected bedding dur- 
ing an entire night. The danger of tubercular infection during travel 
may be intensified by the lack of proper ventilation, for when an indi- 
vidual is confined in close, stuffy quarters, the irritation of the respira- 
tory tract may be sufficient to increase his susceptibility ; or an already 
infected individual may have an inflammatory condition of the lungs 
intensified by foul air or draughts, thus changing a latent to an active 

92 



NAT. ASS'N for study AND PREV. OF TUBERCULOSIS 93 

infection. Admitting that tubercular infection is not apt to occur 
during any single trip in a day coach, we must still appreciate the 
fact that exposure in such coaches is possible, for many people 
spend a considerable amount of time each day in city and suburban 
cars on their way to and from business. 

The important question then is: Are cars properly cleaned and 
ventilated ? Some one in authority should be able to answer this ques- 
tion. Let us quote a few opinions bearing upon the possible danger of 
tuberculosis infection in cars. 

One sanitarian from a state where there is much tuberculosis 
says: 

Regarding the question of car sanitation and possible tubercular infection 
of travelers, I consider it beyond any question of doubt that tubercular infection 
may be transmitted from infected cars to passengers. I do not believe, however, 
that this often occurs, for the reason that travelers are in the cars for a short 
time only, but I can readily understand how infected cars might be the means of 
subjecting individuals having a tubercular tendency to the dangers of infection. 
Theoretically, an infected car is as great a source of danger as is an infected 
room, for while in transit there are constant draughts through the car which 
interfere with the tubercle bacilli that may be present in the air settling to the 
floor by gravity. Again, the blankets and permanent fixtures of Pullman cars, 
especially if the berths have been used frequently by tubercular patients, are 
sources of danger even to a healthy individual, for he is brought into close 
contact with these articles. As regards car cleaning: The day coaches are 
seldom subjected to anything but ordinary sweeping, and I can see no reason 
why they should not be a source of danger to the traveling public, not only 
from tuberculosis, but also from other contagious diseases. The lesson I have 
learned while traveling is, that at the end of a journey the ordinary day coach 
is extremely filthy because of the refuse left by passengers. This, of course, 
is not harmful so far as disease is concerned, but it shows a lack of cleanliness 
on the part of the public. 

As regards the question of car sanitation, I think there should be some 
uniform action taken by all the railroads and that all states through their boards 
of health should insist upon this. I believe it is a great mistake for states 
independently to pass regulations relative to car sanitation and attempt to 
compel railroad companies passing through their borders to observe the same, 
for this would cause a good deal of confusion and would not be effective. 

Another state sanitarian says: 

Personally I think the danger of tubercular infection on trains is quite 
exaggerated by the medical profession. Except for trainmen and steady trav- 
elers I think this danger is quite limited. The sleeping-car is probably a consider- 
able source of danger, for often nowadays consumptives may even die on a 
train. The blankets of the Pullman cars are offensive looking and probably 
often actually filthy. 

Another sanitarian says : 

The medical profession of this state, as elsewhere in the United States, 



94 NATIONAL ASSOCIATION FOR THE STUDY 

is practically united in holding that the danger of tuberculosis being communi- 
cated by means of dried sputum, in cars of various kinds, is great 

Another state sanitarian says : 

Our board has never adopted any measures looking to the regulation of 
car cleaning or ventilation. Such measures ought long ago to have been adopted 
to protect the public against the transmission of infectious diseases. I am 
sure the great danger, especially from tuberculosis, is not properly appreciated; 
and not being appreciated, the prevention or necessity for the use of every reason- 
able means of prevention, is neglected. 

Another state sanitarian says : 

There are no laws in this state governing the proper cleansing and ventila- 
tion of street cars, day coaches and sleepers. We authorize the use of the name 
of the state board of health in posting notices against spitting in cars and about 
stations. These notices are used to a limited extent. We also give the officers 
of car companies the right to arrest persons for violating the regulation against 
spitting. So far, however, very little has been accomplished. I am inclined to 
think that the probability of tubercular infection of travelers has been exag- 
gerated. 

Another state sanitarian says : 

The ventilation of steam cars and of all trolley cars is notoriously imperfect 
and the discharge upon the floor of infected oral excrement is constantly oc- 
curring. These conditions are causative of tuberculosis and other affections 
of the respiratory tract. One frequently hears people say : " I have been travel- 
ing for one or two days shut up in a hot unventilated car and have caught a 
cold." This proves that the laity has observed the ill-effects upon health in- 
cident to travel. For myself, I have observed that if I pass two nights in suc- 
cession in sleeping-cars I almost invariably have an attack of rhinitis and 
several times I have had attacks of influenza. I am unusually susceptible to the 
conditions which provoke these maladies. I am aware that the search for the 
specified germ of tuberculosis in cars has not been very fruitful, but nevertheless 
it seems to me that human beings readily find these germs, and so I have arrived 
at the conclusion that steam and trolley cars are fruitful sources of all diseases 
of the air-passages. 

Another state sanitarian says : 

I consider the subject of a proper sanitary regulation for all railroad 
coaches as one of very great importance. So far as I know, the boards of health 
in the different states have no jurisdiction in this matter, but the railroads, real- 
izing the importance of the subject, are doing a great amount of work along 
this line. 

Another state sanitarian says : 

Our board made an attempt to secure legislation last winter requiring the 
proper cleansing of street cars, railway coaches and Pullman cars operated in 
this state, but the bill was reported upon unfavorably, and this was due to rail- 
road influence. That these cars are sources of infection in a large number of 
cases cannot reasonably be doubted. That tubercular infection is possible seems 
but reasonable. Only a few days since a man complained to me that while 



AND PREVENTION OF TUBERCULOSIS 95 

traveling on one of our trans-continental lines he noticed a consumptive in a 
day coach, well advanced in the disease, almost constantly coughing and ex- 
pectorating on the floor, there being no receptacle for receiving the sputum. 
This so disgusted and alarmed the man complaining that he went into another 
coach, which, as a matter of fact, was no better than the one he left. I am of 
the opinion that the time will soon come when the public will demand the en- 
forcement of such measures as I understand have been adopted by the 

road because of the large number of tubercular patients traveling over their line. 

Another state sanitarian says : 

I am one of those who believe thoroughly that greater attention should be 
paid to car sanitation on account of the possibility of the transmission of tuber- 
culosis and other infectious diseases. 

Another state sanitarian says : 

I have had several interviews with railroad officials regarding the sanitary 
condition of cars and they have always expressed a willingness to aid in any 
way possible. The Pullman car, as built and equipped, I believe to be a source 
of danger, and my attention has been drawn to cases of tuberculosis that certainly 
seemed to have been contracted in such cars. I have seen patients in the last 
stages of consumption coughing and scattering sputa all over the blankets, 
cushions and floor. This sputa soon dries and becomes an element of danger. 
I can imagine no better place in which to become infected with tuberculosis 
than in a poorly ventilated car. All cars can and should be so built as to per- 
mit of proper ventilation without freezing passengers or blinding them with 
dust. . . . All cars should be emptied of passengers at least once a day and 
properly cleaned. No car should be cleaned while occupied. The use of the third 
sheets in the Pullman cars will do some good, but it will not keep the blankets 
from being contaminated nor will it remove the need of their disinfection. 

Another state sanitarian says : 

I confess I regard the sanitation of railroad cars as a difficult problem. It 
seems to me, however, that sleeping-cars employed on lines transporting tuber- 
cular cases to and from the south should be disinfected at the end of each run. 
I doubt whether many cases of infection of travelers occur on the cars, but I 
have no means of proving this. One thing that has impressed me as most ob- 
jectionable from the sanitary point of view in car management is the sweeping 
of the floor and dusting of the seats by the porter while the car is full of people. 

Another state sanitarian says : 

In 1904 our board sent the following to all the railway companies operating 
in the state: 

"Resolved, That the present method of sweeping railway coaches 

while in transit is a nuisance and is dangerous to public health, and the 

railway companies are urged to adopt some more sanitary method." 

Our resolution was in the nature of a request, rather than a demand. Even 

if our suggestion was carried out, this would not entirely eliminate the danger 

of infection from tuberculosis, etc., but it would certainly make traveling in day 

coaches more agreeable than it now is. You are undoubtedly familiar with the 

present custom of the porter to roughly sweep the coaches occasionally with a 

dry broom; it seems to be his particular ambition to get as much dust into the 



96 NATIONAL ASSOCIATION FOR THE STUDY 

air as possible. I have happened to be in a smoking-car several times when the 
atmosphere was almost choking because of the dust present. I think car sani- 
tation is one of the most important subjects we have to deal with and that we 
pay altogether too little attention to it. The one thing I think of when I get 
into a berth is whether or not a spitting consumptive occupied it the night 
before and possibly expectorated on the curtains, or wiped his mouth with the 
blankets. 

Another state sanitarian says : 

I regret that absolutely no precautions are taken in our state to prevent 
possible tubercular infection in cars. We tried to pass a law through the last 
legislature that would require sanitary regulations in common carriers, but the 
bill failed to pass the senate after having received an almost unanimous vote 
of the house. 

Another state sanitarian says : 

We have no laws relating to car sanitation. We endeavored to obtain the 
passage of a bill covering this point, but the bill was thrown out by the senate. 
I feel that the greatest danger to travelers is from the sleeping-car blankets and 
curtain hangings. Personally I fear these more than I do the expectoration on 
the bare floor in day coaches. The carpets of day parlor cars I should think 
would become infected in the vicinity of spittoons. 

Another state sanitarian says ; 

Our board of health has not been given the power to enforce regulations 
concerning the proper cleansing of street cars or railway coaches. Over a year 
ago the board adopted a resolution asking the various railroads operating in 
this state to properly cleanse their cars at frequent intervals, but as we have no 
power to enforce this request it has been entirely disregarded. While I presume 
that the possibility of tubercular infection of travelers cannot be questioned, I 
am personally not inclined to the opinion that this danger is very great. 

Another state sanitarian says : 

There is no law in this state relating to car sanitation. A bill placing 
railway and street car companies under the supervision of the State Board of 
Health was introduced at the recent session of the legislature, but failed to 
pass. I believe the present system is a distinct menace to the public health and 
that tuberculosis and other contagious diseases are sometimes contracted as a 
result of the improper care and disinfection of railway coaches and Pullman 
cars. The only rational remedy lies in the direct sanitary supervision by the 
health authorities, operating under strict but reasonable regulations. 

Another state sanitarian says : 

There are no special sanitary measures taken in this state for the proper 
cleaning of street cars, railway coaches or sleepers. It seems to me there can 
be but one conclusion upon the question of car sanitation and the possible tuber- 
cular infection of travelers through neglect of such. With ten thousand people 
in this state suffering from pulmonary tuberculosis, the large majority of these 
being out of employment and traveling from one relative to another, from one 
friend to another, from one physician to another, in search of health, the germs 
of this disease are scattered broadcast. This is especially true in the transpor- 



AND PREVENTION OF TUBERCULOSIS 97 

tatjon coaches, where crowding, lack of ventilation and light make the danger 
of infection greater than is ordinarily realized. I have endeavored to create 
a sentiment in this state in favor of the protection of the traveling public from 
tuberculosis, but thus far I have not been able to make any definite inroad 
upon the old-established customs. 

One physician reports that one morning on a train he spoke to a 
conductor about a passenger who was spitting upon the floor. The 
conductor said there were no rules against spitting on the car floors, 
but there should be. He further stated that he had known several men 
employed as car sweepers who became consumptives after three or four 
years of such work. 

Railway surgeons as a rule do not seem to have very marked 
opinions on car sanitation. One of these officials says : 

This company has a staff consisting of a chief-surgeon and about seventy- 
two district surgeons. The surgical department is only expected to attend injured 
persons and to give opinions in regard to sanitary matters upon request. There 
is no officer w"hose sole duty is that of sanitary expert. Questions relating to the 
sanitation of cars belonging to this company were discussed in correspondence 
between the general manager and the health officer of the city of . 

Another railway surgeon says : 

At the several termini of our road the cars are scrubbed, the movable 
plush seats taken out of the car, exposed to the air and sun, and thoroughly 
dusted and swept. Anything further than this we have never done. 

:\^. . . : • " " f~"T::!?) 

Still another railway surgeon says: 

Our road employs no sanitary measures in the care of coaches further than 
the usual custom of taking the cushions out of the car at the end of the trip, 
beating them thoroughly and cleaning the car with the compressed air blast. 

Another says : 

The coaches are thoroughly cleaned at the end of the trip and so far as 
possible en route, care is taken to get rid of all dust and dirt of every kind. Use 
is made of the pneumatic duster, and cushions are removed and cleaned in the 
open air. 

Certain railway surgeons, however, show an interest in car sanita- 
tion, as borne out by the following quotations : 

— We have no sanitary expert and I am sure no means are provided for 
disinfecting cars unless the ordinary negro porter is regarded as sufficient for 
this purpose. I believe that sanitation enforced by law is the first important step 
in the protection of the traveling public. I thoroughly hope that all roads will 
be compelled to disinfect their day cars and sleepers as a matter of routine. 

— I regret my inability to give you any important data on the subject. 
I do not believe that there is any sanitary expert connected with the road which 
I represent. I must confess that car sanitation as it applies to day coaches and 
sleeping-cars may be said not to exist. 



98 NATIONAL ASSOCIATION FOR THE STUDY 

— Infection in transportation is a subject in which we are deeply interested, 
and we are doing everything possible to keep our coaches in good sanitary con- 
dition. Our instructions are posted in every building and station of the entire 
system, and they are fairly well carried out. Every coach is cleaned at the 
end of a run, no matter how short, and a disinfectant is used on the floors of 
the coach and water-closets, and in the cuspidors. We have been instructing 
our trainmen for some time as to the necessity of reporting every case of tuber- 
culosis, or of any person that seems to be sick, on our cars. The foreman of 
the cleaning yards has been carefully instructed in the cleaning of cars. Some 
time ago I was sufficiently interested in this subject to send an expert to a num- 
ber of different railroads to ascertain what was being done in the way of car 
cleaning, and in fact, I have personally given this matter considerable attention. 
I find that we are cleaning our cars as well as we can with the conveniences of 
the present time. I am satisfied that it will not be long before we will have 
a new car-cleaning equipment in which air will be used by suction instead of 
pressure. Such an outfit will take care of the dust and dirt instead of blowing 
it off onto something else, as is now done with the compressed air outfits. The 
only trouble at present is to get an equipment of the suction type that is reliable. 

— While I have no positive evidence that any one has ever been infected 

with tuberculosis while traveling over any part of the system, still I am 

convinced that it is possible for such infection to occur because of the fact that 
many patients suffering from tuberculosis travel on our trains. These cases 
are often far advanced and are careless as to the deposit of their sputum; even 
in cases where the sputum is deposited in cuspidors I am sure that the upholster- 
ing and other articles of furniture become infected from the showers of finely 
divided sputum expelled from the mouth with every effort of coughing. I be- 
lieve that infections occur more frequently from these showers than from masses 
of sputum deposited in the ordinary receptacles. About two years ago the chief 
surgeon suggested to the management of this system that every passenger car 
be provided with paper cuspidors, and that these be placed at the disposal of 
every one suffering with a cough. After discussing this proposition thoroughly 
it was concluded that the suggestion was not practicable. Still, in my own 
mind, this would seem to be a helpful provision. In my opinion tubercular 
patients should occupy separate compartments or a separate car, for as I have 
stated, the dangers from the showers of finely divided particles of sputum are 
quite as great as from the larger masses of sputum. 

— A conference of the chief surgeons of the related lines has been 

arranged for, and at this conference the question of uniform rules for the 
cleansing and sanitation of cars will come up for consideration. I feel con- 
fident that at this conference we will recommend to our roads for adoption 
every reasonable pi-ecaution that suggests itself to us for the better protection 
of the traveling public on our lines. 

— I believe that tubercular infection in cars limits itself to sleeping and 
especially to tourist cars. Our day coaches are thoroughly cleansed by means 
of washing with damp cloths, the use of dusters and brooms, and thoroughly 
aired in the sun. No antiseptic solution of any kind is used except in a car 
that has carried a passenger ill with a contagious disease. No sanitary expert 
other than the chief surgeon is connected with this road. It is my opinion that 
the danger of infection with tuberculosis from a day coach is much less than that 
from a hotel. Tourist cars and overland sleepers which carry consumptives 
nearly every trip should be disinfected and cleansed thoroughly at the end of 
each trip. 



AND PREVENTION OF TUBERCULOSIS 99 

— With reference to sanitary measures taken by our road in the cleansing 
of cars I am obliged to say that we do not do much. I am glad you are stirring 
up this question and I think it is worthy of attention. It has been impossible 
for us to introduce any systematic method of car disinfection except on the lines 
running through the state where we conform to the state laws. 

— There is no routine disinfection of sleepers or day coaches that have 
been occupied by tuberculous patients. I wish to say, however, that this matter 
is receiving attention from the operating department of the road at the present 
time, a file of correspondence relating to the subject having recently passed 
through my hands. There is no sanitary expert — medical or lay — connected 
with the road at this time. With regard to my views upon the question of car 
sanitation, I am heartily in sympathy with any systematic work that is being 
done or may be done in this direction. 

— One of the great dangers of infection from tuberculosis is the unsup- 
pressed spitting habit, particularly in public conveyances. While making a trip 
recently on the line I noticed an instance where a passenger was ex- 
pectorating on the floor of a first-class passenger coach from the time he 
entered it until he left the train, apparently showing utter ignorance or indif- 
ference to the dangers of such action. 

Many of the city health officers seem to consider that their respon- 
sibilities extend no further than the securing of anti-spitting ordinances. 
These ordinances, it may be stated, are becoming quite general and are 
being enforced to a greater or less degree. A few opinions follow : 

— This city has an anti-spitting ordinance. There is also an ordinance 
requiring that street cars be fitted with ventilating windows, but the personnel 
of our sanitary force is not large enough to do all that we would desire in the 
enforcement of the spitting ordinance, and the ventilation ordinance is vague 
and indefinite. We have tried to improve matters by addressing ourselves to 
the corporation heads, but this has proven a useless task and we are con- 
templating more drastic, but less polite means of gaining the desired end. 

— The only sanitary measure in force in this city as relates to car sanitation 
is the anti-spitting ordinance, which is a very broad one and includes specifically 
the protection of all cars and platforms. This ordinance is now being enforced 
with very happy results. We have no regulations bearing upon the ventilation 
of cars. The street-car companies endeavor to obtain some ventilation of the 
cars through deck ventilators, but unfortunately the conductors do not give 
this much attention. I cannot but feel that in our sleeping-cars there is con- 
siderable danger of tubercular infection because of the lack of good ventilation 
and the proper care on such cars of people suffering from tuberculosis. I have 
never observed that a porter gave any more attention to a tubercular patient 
than to a perfectly healthy passenger. It is difficult to obtain any positive 
evidence of any tubercular infection resulting from crowding in cars, and in my 
opinion such dangers must be very slight when the anti-spitting ordinance is 
thoroughly enforced. I am in sympathy with any measure looking to the better- 
ment of sleeping-car conditions. 

— I have no hesitation in saying that the average car, whether street car, 
day coach or sleeping-car, is badly ventilated, badly heated and badly cleaned. 
Cars of various kinds, but especially sleeping-cars, present many conditions 
favorable to the spread of consumption. 



lOO NATIONAL ASSOCIATION FOR THE STUDY 

— It is almost impossible for this department to secure the proper cleansing 
and ventilation of street cars in this city. From the reports of our inspectors we 
learn that the street cars are washed with water and soap every second night. 
I do not doubt the possibility of tubercular infection in day coaches, but more 
especially in sleepers. 

— Personally I believe the danger of spreading tuberculosis through in- 
fected cars is not very great. The infection, I believe, must come quite directly 
from mouth to mouth; and this brings into consideration the danger from the 
overcrowding of street cars during the rush hours. 

— As relates to car sanitation no official action is taken in this city either 
in connection with the street cars or the various railways centering here. To 
the best of my knowledge, none of these companies have any sanitary expert 
whose duty it is to look after the condition of the cars. I know nothing of the 
steps taken in the sanitation of railway cars, but I feel strongly on this subject. 
I think from what I have heard that the sleeping-cars are rarely if ever dis- 
infected, and I know from personal experience that they are pretty dirty. 
I have a suspicion that the use of dark blankets in sleeping-cars is for the pur- 
pose of lessening the amount of cleansing. One of my medical friends told 
me the other day that his children contracted scarlet fever in the private com- 
portment of a sleeping-car. An official advised him never to take this com- 
partment of a sleeping-car, as that was the room always taken by sick people 
and so far as he was aware, it was never disinfected. 

— So far as street-car sanitation is concerned in this city there is nothing 
done except that the companies keep the cars clean. The ventilation of the cars 
is very defective. This winter I addressed a communication to the general 
managers of street-car lines, calling their attention to these defects and suggest- 
ing changes. All promised to take up the matter and do what they could, but 
so far as I can observe nothing has been done and there is no law regulating 
these conditions. This city has never passed an ordinance looking to the control 
of tuberculosis, but there is now pending before the municipal assembly a bill 
prepared to cover this measure. I have given considerable thought to the dis- 
infection of sleeping-cars. It is well known that a large number of persons 
suffering from tuberculosis travel to the Southwest and West seeking some 
climate which they think may be beneficial. The cars carrying these people 
should be disinfected. Probably the best way to solve these questions would be 
to agitate the matter and force the transportation companies through public 
sentiment to adopt rules by which the proper care of cars may be secured. Un- 
less the railroad companies voluntarily take up this matter I am of the opinion 
that little can be accomplished through state or local officials. 

— There are no special sanitary measures taken in our city relative to the 
cleaning and ventilation of street cars. We have so far been unable to per- 
suade or compel the local street-car company to clean and ventilate its cars 
properly. The same may be said of the railroads entering this city. There is no 
sanitary expert — medical or lay — connected with the street-car service, nor do 
I know of any such expert connected with the railroad. The railroads do not 
give this matter much attention because there is no money in it. I. think tuber- 
cular infection may be conveyed in street cars only to those persons who are 
particularly susceptible to this disease. 

— In April of last year we passed an anti-spitting ordinance, and since that 
time many fines have been imposed. We have no ordinance governing the 
cleaning and ventilation of street cars. Believing as I do that tuberculosis is 
infectious, I feel that special care should be taken in the cleansing and ventila- 
tion of railway coaches, and especially of sleeping cars. 



AND PREVENTION OF TUBERCULOSIS lOI 

On December 31, 1904, the Imperial Austrian Railway Department 
issued the following : 

WARNING 

FOR THE PREVENTION OF TUBERCULOSIS 

Promiscuous spitting is strictly forbidden; persons violating this 
law will be liable to a fine of 2-200 Kronen, or to arrest for a period 
varying from six hours to fourteen days, in accordance with the regu- 
lations of September 30, 1857, Imp. Legal Code, No. 198. 

IMPERIAL AUSTRIAN RAILWAY DEPT. 

A sufficient number of spittoons must be placed in all waiting-rooms and 
station-halls, on the platforms, in the station restaurants and railway trains 
and in carriages wherever possible. 

All spittoons must be placed on the floor. 

As the use of the spittoons is intended to render the sputum of con- 
sumptives innocuous, and thereby aid in the combatting of tuberculosis, the 
vessels must in shape and utility correspond in the main to the following hygienic 
principles laid down by the board of sanitation. 

1. The shape of the vessels must be such that it is easy to spit into them, 
so that the outer surface of the spittoon and the floor may not be made unclean, 
either at the time of expectoration or by the upsetting of the vessels. 

2. The sputum shall as far as possible be concealed from view. 

3. The vessels must be of such a nature that they can be easily and quickly 
emptied and cleaned, and it must be possible to carry out this operation in such 
a fashion that neither the hands, the body, the clothes, nor the surroundings of 
the person attending to it shall come into contact with the sputum. 

4. The drying of the sputum in the vessels shall be avoided by the partial 
filling of the same with water. 

Disinfection of the sputum is not necessary; it is sufficient if the contents 
of the spittoons, together with the liquid employed in the cleansing of the latter, 
are emptied into the sewers, canals or sinks. 

The so-called hygienic spittoons which have up to the present been most 
in use do not correspond to these requirements because the surface of the fun- 
nel is almost level, to the outward-bent edges, and,. in some spittoons, to the 
outward-bulging sides of the vessels, whence it is apt to be brushed away by 
women's skirts. The soiling of the hands with sputum in cleaning vessels of 
this shape is, moreover, difficult to avoid. 

In the passenger trains the type of spittoon employed must be chosen 
with due regard to space consideration and to the continual motion of the 
carriages. 

In order to diminish as far as possible the above unsatisfactory conditions, 
the railway department considers it necessary to introduce higher-standing ves- 
sels of granite-enamel with a more sloping funnel arrangement, whose upper 
edge shall lap over the edge of the vessel itself at as sharp an angle as possible. 

These vessels must be 14 centimeters high, and must have a diameter of 
22 centimeters from edge to edge above and about 16 centimeters below. 

The diameter of the lower opening of the funnel-piece shall be 8 centi- 



102 NATIONAL ASSOCIATION FOR THE STUDY 

meters, and this aperture shall be 3 centimeters above the floor of the vessel. 
In order that the vessels shall comply with the above requirements (Point 3) 
as to cleaning, the bowl of the vessel and the funnel-piece must both be provided 
with suitable handles for grasping and holding them during the cleaning, which 
is done with long-handled brushes. 

In these spittoons the brushing away of the sputum is made less probable 
by their height, as the hems of women's skirts will rather brush the sides than 
the upper surface, and because, moreover, the sputum does not stick to the 
steep sides of the funnel-piece so easily. 

Such spittoons are gradually, according to the funds at disposal, to be 
placed not only in passenger carriages but also in railway restaurants, waiting- 
rooms, halls, on platforms and in the rooms of the officials to which travelers 
or the public have access. In other rooms, which are only used by the railway 
officials, such as offices, workrooms, stores, barracks, etc., those spittoons may 
be employed which have up to the present been used and which, although not 
corresponding to the specified type, can yet be partially filled with water. 

If, however, it also becomes necessary to procure new spittoons for the 
last mentioned rooms, these must be of the type prescribed for the first men- 
tioned cases. 

Models of spittoons recognized as suitable may be obtained in the factory 
of Ernst Glogar of Vienna, XII, Gierstergasse, No. 7. 

Continual care must be given to the thorough cleaning of the station 
premises and carriages at regular periods corresponding to the frequency of 
the use. 

In order to instruct the traveling public concerning these measures for the 
prevention of tuberculosis, and to arouse in them an active interest in the carry- 
ing out of the same, an extract from the resolutions concerning the public will 
be remitted to certain daily papers by the railway department. 

The entire staff of the railways shall, by means of a circular, receive de- 
tailed information concerning the nature of tuberculosis, the measures for its 
prevention, especially as regards the danger from expectoration on the floor, 
and other hygienic regulations with reference to the prevention of tuberculosis 
— the airing and cleaning of the carriages and of rooms set apart for the use 
of railway personnel and the industrial hands, and for dwelling purposes. 

The staff is also to be warned, on the penalty of a fine, not to set a bad 
example to others by spitting on the floor. 

The staff is to be instructed in and examined on the contents of the circular. 
Moreover, accurate instructions must be given to the men employed on the 
station and to those occupying the trains, with regard to their conduct toward 
the passengers violating the regulation prohibiting expectoration. The men 
must, in cases of transgression, notify the state or police authorities of such cases. 
All the officials and railway physicians shall be supplied with a special 
official copy of the Imperial Austrian Ministry of the Interior, July 14, 1902, 
concerning the measures to be taken for the prevention of tuberculosis, and the 
instructions contained therein shall be observed to the very letter. 

Railway physicians are bound to suitably instruct the railway workers and 
their families or fellow-lodgers as the above-mentioned enactment prescribes, 
and moreover to notify their superiors of cases of advanced tuberculosis. 

Clothes, linen and various articles in use, as well as the rooms of tuber- 
culosis railway workers or their families, must, on every change of dwelling 
or on the death of such tuberculous persons, be dealt with according to the 
measures prescribed on page 8 of the above-mentioned separate copy; these 



AND PREVENTION OF TUBERCULOSIS IO3 

measures, moreover, refer not only to the uniforms of the men, but to all clothes 
used by the patients in question, and also to the ordinary lodgings and the 
offices used by such invalids. 

It is advisable to disinfect in steam disinfectant apparatus all such garments 
as are likely to be spoiled by boiling or soaking in liquid disinfectant. The 
previously mentioned dwelling-rooms and offices should be re-whitewashed on 
every such occasion, and the floor washed with a soda solution. 

The execution of the above sanitary prescriptions must in all cases be 
supervised by the chief officials of the respective stations and by the railway 
physicians, and the organs of the Imperial Austrian General Inspection shall 
from time to time convince themselves that such supervision is actually carried 
out. 

Special attention must be devoted to obtaining scrupulous cleanliness in all 
articles in use in the railway restaurants and kitchens. 

Persons known to be suffering from tuberculosis shall not be employed 
in connection with such work. 

Inquiry throughout the United States shows that there are no 
uniform regulations governing car sanitation. The federal government 
has done nothing to secure such needed regulations. 

The Conference of State and Provincial Boards of Health, at its 
meeting in Washington in 1904, took action as follows : 

Resolved, That the Conference of State and Provincial Boards of Health 
endorse and recommend the following procedure for the cleansing of sleeping- 
cars, coaches and other railway conveyances ordinarily used by the public as 
a safe and efficient method of prevention against communicable diseases: 

1. That all carpets, upholstery, and cloth furnishings that can be removed, 
be thoroughly cleansed outside the car by means of compressed air. 

2. That all cloth furnishings permanently fixed within the car be cleansed 
in situ by means of compressed air. 

3. That floors, platforms, etc., after moistening, be thoroughly cleansed 
of dust and gross dirt by means of compressed air. 

4 That all linen, after being used once, be thoroughly washed before using 
a second time. 

5. That blankets and non-washable fabrics be removed from the car and 
exposed to the action of sunlight for as long a period as possible. 

6. That cuspidors and their contents be thoroughly sterilized by subjecting 
them to the action of steam under pressure. 

7. That cars containing blankets, draperies, etc., exposed, be thoroughly 
fumigated with formaldehyde, using 500 c. c. to each 1,000 cubic feet of air 
space, for as long a period as possible. 

8. That all cars be cleaned in the above manner as often as possible, at 
least once a week. 

9. That distilled water, or water equally pure, be supplied for potable 
purposes. 

Two states, Texas and Kentucky, have formulated regulations. 
Those of Texas are as follows : 

I. It shall be the duty of the state health officer and he is hereby author- 



I04 NATIONAL ASSOCIATION FOR THE STUDY 

ized and empowered to prepare rules and regulations governing the proper dis- 
infection and sanitation of public buildings and all railway coaches and sleeping- 
cars operated in the state of Texas. 

2. It shall be his duty and he is hereby authorized and empowered to 
prescribe a sanitary code which shall contain and provide rules and regulations 
of a general nature for the improvement and amelioration of the hygienic and 
sanitary conditions of said public buildings, railway coaches and sleeping-cars. 

3. Every person having control of any public building, railway company, 
sleeping-car company, or other corporation, company or individual, or the re- 
ceiver thereof, engaged in the carrying of passengers in this state, shall, at their 
own expense, within a prescribed time after receiving notice from the state 
health officer of the promulgation of the rules and regulations in the above 
sections mentioned, carry the same into effect. 

4. If any person having control of any public building, or any agent, 
manager, operator, employee or receiver of any railway company, sleeping-car 
company, or any individual, shall fail to comply with the provisions of this act, 
and the rules and regulations promulgated by the state health officer under 
the provisions thereof, he shall be deemed guilty of a misdemeanor, and upon 
conviction shall be punished by a fine of not less than fifty (50) nor more than 
two hundred (200) dollars. 

Approved April 6, 1903. 

The rules : 

By virtue of the authority vested in me (as State Health Officer) by the 
above act, the following rules are hereby prescribed, which shall govern the 
disinfection and sanitation of public buildings, railway coaches and sleeping- 
cars in the state of Texas, and shall be effective on and after February 11, 1904. 

1. Each passenger coach or sleeping-car used for passengers must be pro- 
vided with one cuspidor for each seat or every two chairs. Each cuspidor 
must contain not less than six ounces of a disinfectant solution approved by this 
department. The cuspidors to be emptied, washed in a similar solution and 
replenished each trip or every twenty-four hours. 

2. Public buildings must be provided with a sufficient number of cuspidors 
or not less than one in each room or hall, treated in a like manner and emptied, 
washed and replenished daily. 

3. The floors of cars and public buildings must be sprinkled with a similar 
solution before each sweeping. 

4. The sweeping and dusting of cars is prohibited in transit, except that 
floors of cars may be swept at division terminals or meal stations where pas- 
sengers will be given an opportunity to leave the car during that time. Seats, 
windows and walls of cars must be wiped off with a cloth or sponge and not 
dusted in transit. 

5. All sleeping-cars must be disinfected by fumigation in a manner approved 
by this department at the end of each round trip in the state of Texas, where 
sleeping-cars do not leave the state. 

6. All sleeping-cars passing through or coming into the state must be 
disinfected in the same manner each trip at some point in the state approved 
by this department, all carpets, curtains, blankets and bedding, except linen, 
to be disinfected with the cars. 

7. Day coaches used for passengers must be fumigated whenever the 
necessity exists at some point in this state acceptable to this department. If a 



AND PREVENTION OF TUBERCULOSIS IO5 

car becomes infected by being occupied by a person having a contagious disease, 
it must be disinfected immediately at the end of the run. 

8. All public buildings must be disinfected by fumigation whenever the 
necessity exists for it. 

9. Containers of water for drinking, in cars and public buildings, must 
be emptied and thoroughly cleansed at least once every forty-eight hours. 
(Public schools should be provided with a separate cup at each desk for each 
pupil to drink from, or the pupils should be required to provide same.) 

10. Ice, which is used in water coolers in cars, must not be dumped on 
the floors, sidewalks, or car platforms, where people have trod and expectorated, 
and then picked up by unclean hands and put into the drinking water. It should 
be washed and handled with ice tongs. 

11. Passengers, patrons, employees or others must be prohibited from 
washing their teeth over or expectorating into basins in sleeping-cars, passenger 
coaches, or public buildings, which are used for bathing the face and hands. 
Large cuspidors must be provided for such purposes. 

All local health officers and citizens are requested to assist in the enforce- 
ment of the above rules. 

Those of Kentucky are as follows: 

1. All day coaches engaged in regular traffic shall be thoroughly cleansed 
after each trip at such points as facilities for same have been provided. In. 
no case shall such cleansing be less frequently performed than on every third 
day of use. In such cleansing, all rugs, mattings and upholstered scats and 
back-rests, when practicable shall be removed from the coach to the open air 
for mechanical cleansing and be exposed to sunlight when the prevailing meteoro- 
logical conditions will permit. 

2. All interior surfaces in coaches are to be mopped, scrubbed or cleansed 
at intervals of not more than ten days, with solutions of mercury bichloride, 
carbolic acFd, tricresol or other disinfecting preparations preferred by any cor- 
poration and approved by this board as to ingredients and strength. 

3. Spittoons are to be provided in numbers of not less than one for each 
seat in all smoking-cars and toilet-rooms, and one at each end of all other day 
coaches, and in all waiting-rooms. Placards provided by this board shall be 
displayed at each end of all such coaches, and in all waiting-rooms, indicating the 
importance of using the spittoons, and it shall be unlawful for any person to 
spit upon the floor, or platform, of any railway car, or other public conveyance, 
or upon the floor of any waiting-room or platform in any station or depot. 

4. All coaches of any kind in which an acute infectious disease has been 
carried shall remain closed and unoccupied after such person has been removed 
until it has been thoroughly cleansed and disinfected by the use of formaldehyde 
gas in quantities of not less than forty (40) fluid ounces of formalin to each 
coach. All day coaches in regular use for through travel are to be disinfected 
after cleansing by some method approved by this board, at intervals of not 
more than ten days. 

5. All toilet-rooms, water-closets, urinals, spittoons and toilet appliances 
are to be scrubbed with soap and hot water and disinfected with formalin or 
other approved disinfectant after each trip's use, and kept as clean as possible 
when on the road, and all similar rooms and appliances in stations shall be 
cleansed daily in the same way, and when vaults or surface receptacles are 
used in stations these shall be disinfected daily with fresh lime. 

6. All preceding regulations in regard to cleanliness and disinfection shall 



I06 NATIONAL ASSOCIATION FOR THE STUDY 

apply equally to sleeping, dining, buffet and parlor cars used in the service of 
the public. 

7. All blankets, curtains and hangings used in sleeping-cars shall be ex- 
posed to superheated steam or other means of disinfection approved by this 
board, at intervals of not more than ten days, and all mattresses shall be so 
treated at intervals of not more than sixty days. 

In speaking of the Kentucky regulations, Dr. McCormack, secre- 
tary of the state board of health, says : 

We are promised the cordial co-operation of all lines operating in this 
state. The Pullman Company has been slower than the other corporations in 
adopting our regulations. We look upon these regulations as the most important 
work our board has ever undertaken and we are supported in our action by the 
newspapers and by strong public sentiment. 

It is worthy of note that two railroads passing through Kentucky, 
the Chesapeake & Ohio and the Louisville & Nashville, have regula- 
lations in force similar to those of the Kentucky board of health. 

I think it can safely be said that as a rule street railway companies 
are not giving sufficient attention to car cleaning or car ventilation. 
There is not the same excuse for this condition with these corporations 
that there is with the railway companies. The city sanitary officials 
have the street railway companies under their jurisdiction and sanitary 
regulations should be in force and enforced. 

The railway officials must be given credit in many instances for 
trying to keep their coaches in good sanitary condition. Many com- 
panies have elaborate regulations governing car cleaning and ventila- 
tion, but these are not always enforced. For example : One company 
which has elaborate rules for cleaning has been reported upon to me 
three times, as follows : 

(i) August 15, 1902. — The sleeping-car, (owned by the railroad 

company) arrived at 7.00 a. m. and left at 6.45 p. m. of the same day. The 
bedding was not taken out, neither were the berths lowered nor the carpet re- 
moved from the car. The man in charge of this car told me that the blankets 
and pillows were taken out of this car and dusted about August i, and that the 
carpet was taken up every eight days. 

(2) August 17, 1902 — The above sleeping-car arrived about seven o'clock 
in the morning and left in the evening of the same day. I watched it from the 
time it arrived until it left. There was absolutely no cleaning of the car beyond 
the use of the feather duster and the broom. 

The same inspector reporting further upon the yards of the com- 
pany owning the sleeper referred to above, states that " absolutely no 
attention was paid to the airing of bedding during my four visits to 
this yard." 

Another company has elaborate rules governing car cleaning, and 



AND PREVENTION OF TUBERCULOSIS IO7 

in the summer time this company does good work in its yards, if one is 

to judge by conditions as I found them on one of my inspection trips, 

yet in December, 1903, report was made to me upon the cleaning in the 

yards of this company, as follows : 

I visited the yards of the Railway Company where the sleeping-cars, 

and , were being cleaned on the inside. (These sleeping-cars were 

owned by the company.) The method employed was: The windows, tops and 
sides of the car were cleaned with dusters, the pillows were taken from under 
the seats, beaten together two or three times in the car and then replaced in 
the pillow boxes. The backs and cushions of the seats were then swept with 
floor brooms. The carpet was swept in situ with a broom, then rolled up and 
placed for the time being in the smoking-room of the car. I was told by the 
men doing this work that this was all the cleaning these cars would get with 
the exception of wiping when the sweeping and dusting were completed; that 
the blankets were shaken about once a month and the cushions taken out and 
beaten when they became very dirty. There was no evidence of compressed 
air pipes or taps in these yards, and I was told by two workmen that compressed 
air was not used in the cleaning of the cars of this company. 

Still another company has elaborate rules for car cleaning, but the 
conditions as shown at several inspections were quite similar to those 
given above. 

One special superintendent says: 

This road has given as much if not more attention to questions relating 
to car sanitation than almost any other road in this country. We happily enjoy 
conditions which permit of a state of cleanliness and correct sanitation that no 
other road enjoys. Our terminals are not far apart and we are thus enabled to 
give the cars the best possible attention after every trip. 

This superintendent, after describing fully their methods of car 
cleaning, states further: 

Relative to car ventilation, it is needless to say that I am thoroughly in 
accord with anything that will better the sanitary conditions of our railroad 
equipment. You, of course, understand that the systems of ventilation are 
being experimented with by many railroad companies and we are constantly on 
the lookout for improved ventilating devices which .will meet the peculiar and 
difficult problems to which car ventilation is subject. My own opinion is that 
a careful drilling of the railroad trainmen in the matter of regulating the deck 
sash and other devices which may be in our cars for ventilating purposes is 
of the greatest importance, and I thoroughly believe that if trainmen can be 
brought to a knowledge of the principles involved in the proper use of the 
ventilating devices now in hand it will go a long way toward correcting bad 
conditions in car ventilation. 

Another special superintendent of this same system says: 

Sleeping cars are stripped once a week by taking out everything removable. 
Mattresses are beaten on both sides, swept with corn brooms and blown out 
with compressed air; blankets are aired and brushed off with whisk brooms 
on both sides; pillows are beaten on both sides and brushed off with whisk 



I08 NATIONAL ASSOCIATION FOR THE STUDY 

brooms; carpets are beaten and blown out with compressed air. When the 
interior furnishings are out the car is given a thorough washing with tepid 

water and , a disinfectant. The floors of the day coaches are thoroughly 

washed each night and mopped dry, and the seat cushions and backs are cleaned 
with compressed air. All of our cars are well ventilated through the decks. 

This last description is fairly illustrative of the general methods 
of car cleaning now in vogue. 

The Pennsylvania system seems to have given a great deal of 
attention to car sanitation, and its methods of ventilation are among 
the best, if not the best, now in practical use. Its ventilating system 
furnishes 60,000 cubic feet of fresh air per car per hour, the equivalent 
of 1,000 cubic feet of air to each passenger seat. It is estimated that 
an ideal ventilation system should supply 3,000 cubic feet of fresh air 
per hour to each passenger, but it has not been considered practicable 
to attempt to secure this amount of fresh air with the ventilating sys- 
tem of the Pennsylvania road. A very complete report on this system 
of ventilation has been made by Dr. C. B. Dudley, chemist to the 
company. 

Relative to car cleaning, the general manager of the system states : 

At every principal terminal, cleaning is constantly going on by gangs 
of women, who clean with soap and water. It is impossible to give a positive 
figure showing how often each car is cleaned, as the emergencies of the service 
interfere with regularity on this point, but the cleaning force is a part of the 
regular organization and is constantly at work. The cleaning of cars in transit, 
t. e., when they are in the train and have passengers in them, is a subject which 
has been much discussed and, as the result of a good deal of study, it has been 
decided not to do any sweeping in transit for fear of raising dust. If, how- 
ever, a car in transit is filthy owing to the spitting of some unclean passenger 
or to difficulties with children, such car when it reaches the end of any division 
is cleaned out with mops. At terminals the cars are dusted with damp cloths, 
and the sweeping, if this is the cleaning given, is done with a brush on the 
end of a long handle rather than with a broom. 

The company maintains a "relief department" which department has a 
staff of over sixty physicians, all of them regular graduates in medicine, who 
devote their whole time to the interests committed to their charge. The organ- 
ization of this department is such that the railroad company has a direct financial 
interest in the health of its employees. It follows, therefore, that if serious sick- 
ness should occur there might result through this department a considerable 
charge against earnings. To obviate, so far as possible, such possibilities, it is 
made a part of the duty of the relief department surgeons to make constant 
inspections and suggestions leading to the elimination of anything which may 
threaten the health of the employees, and as a large number of employees are 
engaged in the train service and in and about passenger stations, the results 
of these inspections are felt likewise by the passengers. Furthermore, meetings 
are not infrequently held by the relief department surgeons, at which papers 
are read, and discussions are held over sanitary problems. At the semi-annual 



AND PREVENTION OF TUBERCULOSIS IO9 

meetings of the operating officers of the road, sanitary questions are not infre- 
quently brought forward and discussed and reports made on subjects which 
have been assigned. The tendency of this work is toward the betterment of 
the service, as far as the health of both employees and the public is concerned. 

In its chemical and bacteriological laboratories, this road is constantly 
examining samples from water supplies, with the idea of excluding from its cars 
any water which may be a means of causing disease. Furthermore, in order to 
learn whether the water in the cars put into the coolers at various points along 
the line is or is not objectionable, a number of analyses have been made of 
samples taken direct from the coolers of the trains in transit. This examination 
of water supplies and of water from the coolers has not yet been made a 
systematic part of the laboratory work, but the examinations thus far made 
indicate a less threatening state of affairs than might have been supposed. 

Although this road does not provide any specific sanitary head, it is fair 
to state that the surgeons and laboratory workers are constantly studying sanitary 
problems, and that when questions arise throughout the system in which the 
public health is involved, such questions are referred either to the head of the 
relief department or to the department surgeons, chemist or bacteriologist An 
attempt is made to keep in touch with the progress of knowledge on sanitary 
questions. 

The Central Railroad of New Jersey is giving much attention to 
car ventilation and cleaning. It is at present using the so-called " auto- 
matic ventilator." This ventilator is said to be simple in construction, 
yet thoroughly -efficient. It seems to be in use on many private cars, 
dining cars, etc., as well as on a few city car lines. It comprises two 
airways in the deck sash, and an outward extension of two wings be- 
tween them. It would seem that if this is an efficient ventilator it, 
or some similar device, should solve the problem of proper ventilation 
for all cars. 

The Central Railroad of New Jersey has also another innovation 
in car sanitation, viz., the use of the " vacuum cleaning system." By 
this system the dust is removed from the cushions, carpets, tapestries, 
etc., by suction and the car after this process of cleaning is free from 
dust instead of being, as under the compressed air system, filled with 
a dust-laden atmosphere. This system, if found efficient, will have 
a further advantage over the compressed air method of car cleaning 
in that it can be used in cars during the winter season in cold climates 
where storm windows are attached, for the dirt of the car is carried 
away without creating any dust whatever. 

All parties seem to agree that the greatest danger to the traveling 
public is to be found in the Pullman car. We would naturally expect 
to find this company fully alive to the sanitary responsibilities resting 
upon it, and yet it had no superintendent of sanitation until March i, 



no NATIONAL ASSOCIATION FOR THE STUDY 

1905. Under date of March 16, 1905, this newly appointed superin- 
tendent of sanitation wrote me as follows: 

Having taken up the af fails of this office so recently, I have not yet been 
able to formulate any definite plans. I shall be for some time occupied in in- 
vestigating the sanitary measures and appliances already in use, and later shall 
give my attention to improving them along such lines as may seem necessary 
for the proper preservation of the safety of the traveling public. We now have 
an arrangement under way for carrying out experiments in car sanitation under 
the direction of Dr. Rosenau, director of the Hygienic Laboratory of the United 
States Public Health and Marine Hospital Service at Washington. This comes 
about through" a request from Dr. Rosenau for a car for this purpose. . . . 
The results of such work will no doubt be of value from the standpoint of the 
public health, and should aid materially in formulating definite plans for im- 
provement. It is the desire of the management of this company to bring the 
sanitation of its cars up to a thoroughly efficient standard. My investigation 
so far has been very gratifying in that it has demonstrated a genuine effort to 
do this for some time past. Of course you will realize the difficulties in the 
way of applying remedies to evils long in existence. It is easier to criticize than 
to apply an efficient and practical remedy. Ideal sanitary conditions exist in 
very few places, nor can ideal conditions be expected until the individuals com- 
prising the public are willing to co-operate in making and maintaining them so. 

Many of the railway officials in reply to my letter of inquiry 
relative to car sanitation, in speaking of the Pullman cars used on their 
lines, stated that they were cleaned under the rules and regulations 
of the Pullman Car Company, and that these rules and regulations were 
in the hands of its district superintendents. I wrote to the district 
superintendent at St. Paul twice for a copy of this company's rules and 
regulations. My first letter was referred by him to the company's 
new superintendent of sanitation. My second letter was not answered. 

However, an official of the railway company sent me a copy 

of these Pullman rules so far as they related to the fumigation of 
cars. I have not been able to secure any rules or regulations govern- 
ing the cleaning of Pullman cars, nor do the rules above referred to 
state the conditions demanding fumigation. The rules governing car 
fumigation are as follows : 

Directions for Using Liquid Formaldehyde in Fumigating Pullman Cars. 

(Revised Instructions.) 

Close the outside doors of a car and all windows and deck sash, leaving 
open locker, drawing-room, buffet, heater, swing and toilet-room doors. 

Lower all upper berths, loosen and disarrange the bedding, so as to expose 
as much of the surface thereof as possible. To accomplish this, remove the lower 
mattresses and place them over the backs of the seats between the sections; 
hang the blankets over the fronts of the upper berths, allowing them to hang 
down about twenty-four inches in front and hang the berth curtains by one 
hook at the end of the berth curtain-rod, the bottom of the curtain being so 



AND PREVENTION OF TUBERCULOSIS III 

spread as to cover as much as possible the woodwork of the end of the seats; 
this will in a great measure protect the woodwork of the ends of the seats 
from being hit by the fluid. (The vapor of the formaldehyde will not affect 
the woodwork.) 

Remove the seat cushions, placing them on end on the floor between the 
seats; loosen the pillows in the pillow boxes. 

Remove the covers from the spittoons, after same have been cleaned, placing 
the latter in the aisle of the car. 

Hang up in the body of the car on the bell cord, four cotton sheets length- 
wise, allowing the sheets to lap over each other some two inches. 

Fill the formaldehyde sprinkler, which is furnished and which holds some 
twenty-two ounces of liquid, up to the glass ring near the top. 

Sprinkle the sheets with the liquid by compressing the rubber bulb, taking 
care to see that none of the liquid gets on the woodwork. The person who uses 
this appliance should have with him a chamois skin, and if by chance a little of 
the fluid gets on the woodwork he should at once wipe it off, so that no harm 
can be done. But one sprinklerful should be used in fumigating a car and the 
sheets should not be saturated. 

When using the sprinkler place the thumb over the top of the open tube 
in the top, make the same tight by slight pressure until the requisite amount has 
been used, then remove the thumb and the liquid will cease to flow from the 
sprinkler. 

The formaldehyde will not injure any fabric or metal. It is not poisonous, 
and can be inhaled for a few minutes without any detriment whatever to a person. 

It is not insecticide. 

In fumigating a car it is well enough for the operative to cover his mouth 
and nostrils with a damp towel, in order to prevent the irritation which will 
take place. 

It ought not to take over five minutes to thoroughly sprinkle the sheets 
above referred to, and when the work is done, the operative should leave the 
car and see that the outside door is closed after him. 

The car should remain closed for four hours or more before it is opened, 
the longer the better, and after this time has expired, the outside door and all 
windows should be opened and the car aired for some two hours or more before 
the bedding is put away. 

A large number of cars can be fumigated in a day, 

Chicago, October 15, 1898. 

Cancel instructions issued September 10. 

I made a second attempt to secure from the superintendent of the 
Pullman Company the rules and regulations governing the cleaning 
of Pullman cars — rules that had been in use before his appointment. 
He replied: 

The matter of regulations concerning cleaning and purification of cars is 
in process of revision. I prefer not to give instructions concerning these things 
until they are put into proper shape and have been transmitted to such employees 
of this company as will carry them out. 

Evidently the doctor was not very favorably impressed with the 
regulations which he found in effect at the time of his appointment. 



112 NATIONAL ASSOCIATION FOR THE STUDY 

It is worthy of note that the copy of the instructions relating to car 
fumigation quoted above which was sent me in March of 1905 is dated 
October 15, 1898. 

The reason for the Pullman Company submitting a car to the 
United States Public Health and Marine Hospital Service for experi- 
mental work is probably explained by the following resolution pre- 
sented in the House of Representatives March 2, 1905, by Mr. Hughes, 
of New Jersey: 

Whereas, Recent published reports of the boards of health of various 
cities and states concerning the ventilation of street and railway passenger cars 
have alleged that there is danger of the communication of contagious diseases 
by reason of the improper or imperfect ventilation of passenger cars. . . . 

Therefore, Resolved, By the Senate and the House of Representatives of 
the United States of America in Congress assembled, that the sum of ten 
thousand dollars be, and hereby is, appropriated, the same to be made immediately 
available, to be expended under the direction of the surgeon-general of the 
Public Health and Marine Hospital Service of the United States, for the pur- 
pose of investigating the possibility of the communication of diseases in street 
cars and railroad passenger cars through the improper or imperfect ventilation 
thereof, and of the possible infection of meats and fruits and other perishable 
food products through the imperfect or improper ventilation of freight cars en- 
gaged in transporting the same, to the end that if, in his opinion, it is thought 
advisable, he shall recommend legislation for the regulation of the ventilation 
of railroad passenger and freight cars engaged in inter-state commerce. 

It should be mentioned at this point that Dr. J. J. Kinyoun carried 
out some valuable investigations relative to car disinfection, etc., about 
ten years ago. At that time he was connected with the laboratory of 
the United States Marine Hospital Service. 

At the meeting of the American Public Health Association at 
Washington, in 1903, Dr. Granville P. Conn made a very exhaustive 
report on car sanitation. At that time, in discussion as well as in the 
report, the Pullman Company was severely criticized as to its methods 
of car sanitation. Shortly after this meeting elaborate articles appeared 
in various parts of the United States setting forth the thorough 
methods said to be in force by the Pullman Company in the cleaning 
of cars. The methods set forth in these articles were in such strong 
contrast to those which inspectors had reported to me as in force in 
the section of the country which I represent that I at once had another 
inspection made of the Pullman methods. The report of the inspector 
did not bear out the claims of the Pullman Company. 

In preparing this paper I have sought information from many 
different individuals. For reasons that are self-evident I appealed to 



AND PREVENTION OF TUBERCULOSIS II3 

those connected with railroad work. Opinions came to me from more 
than a hundred different sources. None of these opinions were against 
the possibility of tubercular infection during transportation in public 
conveyances. Some, of course, argued against the probability of such 
infection, basing their argument largely on the fact that exposures at 
most in public conveyances were for but short periods. In considering 
the possible danger of infection from public conveyances the fact must 
be kept in mind that conditions in cars are not the same as in the 
rooms or houses. The moving car is in a state of constant vibration 
and consequently the amount of dust or of germs in the air will be 
greater at all times under such conditions than in a room. 

All of the opinions given me were to the effect that the greatest 
danger of infection is to be found in the sleeping-car. 

Car sanitation embraces car cleaning and car ventilation. Car 
cleaning is a simple problem, for it is one of dollars and cents. Of 
course there are times and conditions when a car may temporarily be in 
an unavoidably foul condition. This applies especially to street cars 
during certain seasons of the year. Such conditions are excusable, but 
they do not justify general negligence of cleanliness. 

Car ventilation is a difficult problem, for the temperature and the 
motion of the car, as well as the creation of disagreeable draughts, have 
to be taken into consideration. It is estimated that for good ventila- 
tion in a closed space 3,000 cubic feet are required per hour for each 
individual. The ordinary passenger coach and sleeping-car furnishes 
from one-tenth to one-sixth as much fresh air per hour as is required 
according to the above estimate. From a sanitary point of view, the 
effects of foul air as a means of causing disease must not be overesti- 
mated. The fact must be recognized, however, that a person in a badly 
ventilated car is more susceptible to tubercular infection than he would 
be in a well ventilated car. 

The great offenders in car ventilation are the street-car com- 
panies. While the railroad companies are trying to find some satis- 
factory means of ventilating cars it is the exception to see a street car 
equipped with anything but the so-called deck ventilators. It is a safe 
statement, I think, that deck ventilators never will furnish proper ven- 
tilation in any car. This is especially true of the overcrowded street 
car. 

Dr. C. B. Dudley, chemist to the Pennsylvania Railway System, 
in his paper on " Passenger Car Ventilation " says : 



114 NATIONAL ASSOCIATION FOR THE STUDY 

A car is said to be well ventilated when a person coming into the space 
from the outside fresh air detects none of the odor characteristic of a badly 
ventilated space. 

Such a condition rarely exists in any street car in a cold climate 
during the winter season. It is not an uncommon thing to hear street 
car officials attempt to throw the responsibility for the bad ventilation 
of their cars upon the public, the position being taken that the people 
object to the cold air coming in through the ventilators. It is not the 
people, but the ventilators, that are at fault in these cases. Of course 
people will not tolerate strong draughts of cold air upon their heads. 
The ventilators should be so constructed as to supply fresh air without 
the creation of annoying draughts. 

Faulty ventilation is not entirely due to faulty ventilators. One 
of the railway authorities already quoted in this paper says : 

My own opinion is that a careful drilling of trainmen in the matter of 
regulating the ventilation through deck sash or other devices is of the greatest 
importance, and if trainmen can be brought to recognize this fact, it will go a 
long way toward correcting bad conditions in car ventilation. 

This fact is one that street-car companies especially should keep 
in mind. Their cars make short runs and are constantly under the 
supervision of inspectors. These inspectors should note whether the 
conductors are obeying the regulations of the company as to ventila- 
tion at the same time that they are checking up their honesty in money 
matters. My own experience is that companies' regulations often exist 
only on paper. As an illustration: on a pleasant spring day, not too 
cool, I entered a car occupied by but a few passengers. This was about 
noon-time. The air was foul and every ventilator was closed. A 
change of conductors was made at the point where I became a pas- 
senger. The retiring conductor was responsible for the condition of 
the car as I found it. I decided to note what the new conductor would 
do and so said nothing at the time. After traveling in this car an 
hour, as I dismounted at the end of my journey, I asked the conductor 
if there were no company regulations relative to car ventilation. He 
replied in the affirmative. I then drew his attention to the fact that 
every ventilator in his car had been closed during the entire run. He 
then became rude and abusive in his language and told me he did not 
have to open ventilators unless requested so to do by passengers. A 
short time ago a woman living in my home city on entering a car 
noted that the air was very close and foul, every ventilator being closed 



AND PREVENTION OF TUBERCULOSIS II 5 

tightly. She asked the conductor to open one or more ventilators. He 
made no reply, but stared at her in an impudent sort of way and did 
nothing. She then asked a gentleman sitting near if he would open 
one of the ventilators and he did so. The day was pleasant, but 
slightly cool — a spring day. There was no fire in the car. It is pos- 
sible that the conductor thought it necessary to keep his car closed 
tightly in order that it might be comfortably heated with the animal 
heat from the passengers. Whether he was acting on instructions or 
on his own authority in keeping his car closed, I do not know. Cer- 
tain it was that for the sake of warmth the course that he pursued was 
not necessary, nor was it wise from a sanitary point of view. I pre- 
sume many of you have had similar experiences. The manager of the 
company employing the two conductors referred to says: 

The matter of proper ventilation is perhaps the most troublesome feature 
of street railway operation, the air very often becoming foul simply because cer- 
tain of the passengers object to having it otherwise. In any event they are not 
willing to have a sufficient number of ventilators open for such length of time 
as may be necessary to change the atmosphere. Because of this fact our em- 
ployees are instructed that when within two or three blocks of terminals, and 
when the car is generally empty, the front and rear doors are to be opened, 
allowing the air to go through while the car is in motion. Our standard cars are 
equipped with four deck ventilators on each side, two near the front and two 
near the rear. 

In spite of the above statement, it was very seldom that a con- 
ductor opened the front and rear door of cars near the end of the run 
over which I have traveled almost daily for some time. There was a 
time when the commissioner of health in one of the two cities served 
by this line did insist on this order being enforced in the city which he 
represented, but when this commissioner's vigilance waned, the vigi- 
lance of the conductors waned also. 

After a careful consideration of the facts presented in this paper I 
think we must all admit that there is a real, but unnecessary danger of 
infection with tuberculosis during transportation in many of the cars 
operated by city railway companies, by railroad companies, and by the 
Pullman Car Company. 

In closing I wish to thank those who have been so generous in 
supplying data bearing upon car sanitation. The heads of the mechani- 
cal departments of the various railroads are especially deserving of my 
appreciation. 



Il6 NATIONAL ASSOCIATION FOR THE STUDY 

DISCUSSION ON DR. BRACKEN'S PAPER 

Dr. T. R. Crowder, Superintendent of Sanitation, Pullman Com- 
pany : I really came here in order to learn what might be brought out. I 
have never thought of tuberculosis as it applies to transportation, but it 
seems to me to be a broad part of the problem. Almost ioo% of us 
have tubercular disease in some part of our body and it seems to me 
that we must go far back and educate the personal hygiene of the tuber- 
culous subject. From the widespread nature of the disease we are to 
suppose that tubercle bacilli exist in practically all places. As regards 
sanitary affairs and the management of the sleeping-car or of trans- 
portation in general, we must remember that the men who manage these 
concerns are laymen. We are not to expect that the opinions these 
men have will be other than those held by the general public ; they are 
not teachers of personal hygiene, but they are men who are willing to 
accept all reasonable suggestions for the improvement of sanitary con- 
ditions. In so far as suggestions are practical they are willing to 
preserve the public health to the best of their ability. I have been in- 
duced to take up the subject of sanitation for the Pullman Company 
because the man at the head of that company realizes that this question 
is going to be of frequent occurrence and is beyond the laymen's ability. 
A layman is incapable of selecting the best things to be done and deter- 
mining what things must be remedied. As to what has been done on 
the part of the Pullman Company, their improvements began 5 years 
ago by building their cars with a simpler inner furnishing. The cor- 
ners were rounded off and ledges were done away with. The cars now 
have the simplest possible interior so that they may be easily cleaned. 
They have begun putting in rubber tiling in the smoking-rooms and 
lavatories and in all parts of the car except the body, which it is in- 
tended shall be covered by carpet. In the matter of carpets and cover- 
ings of the seats there has been no suggestion which it has seemed 
would be permissible in the eyes of the traveling public. Until the 
public demands the change it cannot be made. The closets have been 
equipped with flushing hoppers instead of the old-fashioned dry ones 
and traps are put into the basins. The most important improvement 
that I think has been made is the putting in of a third sheet for cover- 
ing over the top of the blanket. The sheet covering the lower side of 
the blanket protects the berth material entirely from the occupant and 
prevents the materials coming in contact with any future occupant. 



AND PREVENTION OF TUBERCULOSIS llj 

As to car cleaning it has seemed to me that Dr. Bracken has had rather 
insufficient information on this point. From my investigations which 
have been rather thorough, the cleaning is about as follows: When a 
car comes into the yard it is opened up; the seats, cushions, blankets 
and bedding are taken outside to the rack and are blown out with com- 
pressed air ; the interior of the car is gone over and the woodwork is 
cleaned with moist cloths while the floors and closets are scrubbed out 
thoroughly. The hoppers wash out the closets in a way that has never 
been done before. As to the disinfection of cars. Dr. Bracken gives 
expression to the opinion that a car is immediately used again if a 
patient has died in it. As a matter of fact, if a person who is sick has 
occupied a berth, that berth is never sold again until the car is fumi- 
gated. This rule is observed all over the Pullman lines. There are 
certain lines on which they fumigate the cars regularly, especially those 
cars which run into health resorts. Some states insist upon this and 
there is no disposition on our part to shirk responsibility. As to the 
methods of disinfection of the cars, in some cases they have been de- 
fective, but it has been done according to the rules, i. e., by using a 
liquid solution of formalin. This is left to evaporate with all the 
berths open, usually for twelve hours but sometimes only for six, and 
this is done when the car goes into the yard from its trip. If there has 
been a sick person on the car this disinfection is more thoroughly done, 
but we have not yet found an ideal method of fumigation. So soon 
as we can do so we will inaugurate it, apply it to all lines and use it 
where there is the slightest need of fumigation. Wherever a tuber- 
culous patient has been carried, that car is fumigated at the end of the 
trip. Where smallpox and such diseases are discovered the car is 
turned over to the local health authorities. I did not look up the old 
files to acquaint myself with the method in use, but preferred to go to 
the yards and find out for myself. The letters I received from Dr. 
Bracken did not ask for any definite information, but if I had known 
what was intended by his inquiry I could have answered the author of 
the paper better. Carpets are taken out every time the car is thoroughly 
cleaned and if there are any visible signs of soiling they are thrown 
out and others substituted. 

Dr. H. M. Bracken, St. Paul : I do not wish to be too hard on the 
Pullman Company. Some of the methods mentioned in my paper, but 
which I did not have time to read, were very good. It must be borne 
in mind that the car cleaning is not always done according to the regu- 



Il8 NATIONAL ASSOCIATION FOR THE STUDY 

lations. I have sent inspectors to watch the railroads and watch the 
cleaning. These men have secured much accurate information. 

Dr. T. R. Crowder, Pullman Company: It is a rule of the Com- 
pany that no known infectious disease shall be carried, but this rule 
cannot be enforced. The man who sells the tickets does not know 
anything about a person's health. 

Mr. Paul Kennaday, New York : One important point is the pub- 
lic's taste for ornamentation, and it is a question whether or not the 
public would approve of, say leather, as a common covering for the 
chairs. 

Dr. T. R. Crowder, Pullman Company: I do not know how the 
public would view leather trimmings. It has been suggested that 
colored blankets be used instead of white, as they would not soil so 
quickly but the objection is that a colored blanket will not show the 
coal soot as quickly as white. The taking up of the carpet in the car 
is quite a problem. 

Dr. J. N. Hurty, Indianapolis : I was at first inclined to believe 
that the Pullman Company was in the business fpr revenue only, but 
I now think they are trying to do the best they can for the public. The 
Company is anxious to go to the limit in accommodating the public. 
It must be remembered that a large percentage of the people who travel 
in Pullman cars are not cleanly themselves. The carelessness of men 
in using the cuspidors and throwing papers and lunch baskets about 
is terrible. If the people are not cleanly, bad conditions will necessarily 
prevail, but of course the cleanliness of the individuals cannot do away 
with the necessity of cleaning the cars. Under all the circumstances I 
believe the car cleaning is done as well as is the disinfecting. The im- 
provements are coming very rapidly. I remember the white blanket 
was suggested four years ago. There is a great deal of material which 
is not filth in the ordinary sense of the word. Some of the blankets 
are in better condition than the garments of the people who use them. 
The covering of the blanket by a third sheet is an advantage, but it is 
not perfect; however, it is an improvement and the credit should be 
given to the officers of the Pullman Company. The Indiana State 
Board of Health has taken the matter up and rules and regulations 
will be drawn up and issued. Railroad and trolley authorities will be 
invited to send representatives to consider the matter. 

Mr. McDonell of the Pennsylvania Railroad : I was sent here 
in the hope that some suggestions might be offered that I could 



AND PREVENTION OF TUBERCULOSIS IIQ 

take home and have applied for the benefit of the public. The Com- 
panies are desirous of giving good service and our Company has re- 
cently gone to great expense to introduce the best known ventilating 
device. They have made hundreds of tests of disinfectants, and are 
trying to get the most reliable water supply at places where the water 
is known not to be good. The Company is willing to go to any ex- 
pense if they can be convinced of the necessity for such action, and if 
they are convinced that they are justified in the expenditure. If special 
devices are necessary to prevent them from spreading tuberculosis they 
will attend to it if you convince them of the necessity. The Railroad 
companies believe that the danger of the cars is very remote as shown 
by the records of the Relief Department. In i8 years, with 283 cases 
of disablement the number of cases from tuberculosis is not as great 
as in men who follow other walks of life. There is probably not much 
risk in living or working in passenger coaches. We have data show- 
ing that the danger of infection from tuberculosis by the inhalation of 
pulverized sputum is not as great as is popularly supposed. One of 
us will at some future time present some of this data. Sometimes the 
rules offered by sanitarians are not practicable. As to moistening the 
floors and then drying with compressed air, this is not practicable. As 
to disinfection periodically, we use formaldehyde continually. From 
hundreds of tests which we made in connection with this matter we 
found that formaldehyde will not disinfect unless the atmosphere con- 
tains a certain amount of humidity. If an excess of humidity is ob- 
tained and a moisture deposits itself in certain places it absorbs the 
gas, in which case no amount of airing will take this out of the room. 
The result therefore is a constant source of irritation and for this reason 
we do not desire to use this method. 

Dr. J. B. Kaster, Chief Surgeon, Atchison, Topeka and Santa Fe 
Railway System : The railroad company is a* financial institution and 
it employs men for the purpose of making its property pay a few 
dollars of interest to the holders of stock in it. The railroad company 
is willing to expend any amount of money necessary to make the cars 
clean and safe from the fact that the people are becoming educated 
to the question of infection by tuberculosis. The company that I 
represent, and all others are not only ready but willing to adopt any 
reasonable, practicable manner of disinfecting that you can suggest. 
The trouble in the fumigation of cars has been that in order to do it 
it was necessary to seal the ventilators so that the gas could be con- 



120 NATIONAL ASSOCIATION FOR THE STUDY 

tained for a time. The time required to fill the cars with the gas and 
then get rid of it afterward is too great and twice the cars would be 
necessary to carry out this arrangement. I believe you will all agree 
with me that it is up to the physicians and scientific bodies to furnish 
us with some practical way of fumigating the car. I have learned 
there is such a way, but the only question is to be able to do it quickly 
enough. 

As to what has been said in reference to the prevalence of the 
disease among the men who run the cars, I would state that tubercu- 
losis is not prevalent among the men who run passenger trains. The 
health of the conductor and the brakeman is better than that of any 
other class of employees that we have. The car cleaners are said to 
have the disease very often, but this has not been my experience in the 
last twenty years and statistics do not show it. One reason is that the 
men do not stay in this kind of position very long. Possibly they would 
contract the disease oftener if they stayed in the business longer. The 
Pullman porter and the Pullman conductor are given lines of braid 
for their sleeves, each line representing 5 years of service, and it is 
not unusual to see a porter or conductor with four of these braids. 
It seems to me that if there was such a great danger we should not 
find quite so many wearing the stripe on the sleeve. 

The Pullman and the railroad cars have improved much in the 
last few years and the greatest improvement of late has been the 
addition of the third sheet. It has at least a healthful appearance 
and looks right. I am not referring to the cleansing of the cars at 
present, but in Texas the law requires that a car running through that 
state shall be fumigated throughout. Not only do they fumigate the 
car, but they must furnish every seat with a spittoon and the cars 
must not be swept while in motion, as the Texas law prevents this 
being done. The cars can only be swept at a point where the pas- 
sengers may leave it, and it must then be done with a moist rag. Sev- 
eral regulations are rigidly enforced and all railroad companies will 
gladly carry out any instructions. The question has been suggested 
that we should have a hospital car for the transportation of tuberculous 
patients, but the man who suggested that did not suggest a law which 
would compel a patient to go into that car. The dangerous man on 
the railroad is the man who is in the first stages of consumption and 
not the man who is in the third stage and is too ill to move around or 
be a danger to anybody. Until we have a law allowing the railroad 



AND PREVENTION OF TUBERCULOSIS 121 

company to examine every man who presents himself for a ticket we 
cannot do what is expected, but we will be very glad to have sug- 
gestions. 

Dr. R. L. Graham, of the Metropolitan Street Railway Co., New 
York: In connection with the dangers of tubercular infection in the 
Pullman car may be mentioned the dangers of infection in the ordinary 
street-car, which are comparatively slight, and this is especially true 
of the open car. The railway companies are ready to meet any prac- 
tical suggestion towards the improvement of the sanitary condition. 
It can safely be said that the Health Department has found that all 
its wishes have been fulfilled on the part of the New York City rail- 
ways. We have a thorough system. Once in every 24 hours the car 
is placed on the siding and scrubbed thoroughly with soap and water. 
The floors are sprinkled and swept out and the windows wiped off 
with a damp cloth. The majority of the seats are of the carpet variety. 
As often as possible the cars are put in the barn, which is about once 
every ten days, when the carpets are taken off and beaten and the wood- 
work and floors are scrubbed. Subsequent to the scrubbing a liquid 
disinfectant is used. 

In conjunction with other measures to curtail the spread of in- 
fectious disease they have cooperated with the Board of Health, such 
as having a sign, measuring 8 x 22 in each car, saying that spitting on 
the floor is prohibited. The conductors are instructed to see that 
this law is carried out and anybody expectorating profusely on the 
floor is to be arrested. It is easy to find out whether or not a con- 
ductor has fulfilled his duty by inspecting the cars on their return to 
the barn. As to car ventilation the companies are hampered by the 
action of the passengers, those standing objecting to the draught from 
above if the ventilators are open. The conductor is instructed to see 
that the air is kept free from odor and as fAr as possible to keep it 
pure. A great danger is in the actual contact with the tubercular germs 
through the dust coming in through the ventilators. The Pennsylvania 
Railroad has fine netting that to a great extent excludes the cinders, 
but the weave is not fine enough. A movable screen made of cheese- 
cloth might be better. The Long Island Railroad allays dust by the 
use of petroleum along the line. 

Dr. V. C. Vaughan, Ann Arbor, Mich. : It is exceedingly difficult 
to be absolutely certain where any individual afflicted with tuberculosis 
receives his first infection. However, that railroad-cars, and especially 



122 NATIONAL ASSOCIATION FOR THE STUDY 

Pullman sleepers, do sometimes scatter infection quite widely was 
shown by the notorious example of the distribution of smallpox some 
years ago, A patient with this disease in an unrecognized condition 
took a sleeping-car at New York and travelled westward. Two sleep- 
ing-car conductors became infected and finally one of these was carried 
to the general hospital at Montreal and several hundred cases of 
smallpox resulted from this exposure. The agent who is representing 
the Pennsylvania R. R. thinks that there is not much positive evidence 
that the railroads aid in the distribution of tuberculosis, but many of 
you will remember that in Germany Cornet inoculated guinea-pigs with 
dust swept from the floors of cars and obtained quite a number of 
positive results. 

I was asked some years ago to examine a so-called disinfectant 
used on one of the greatest roads in this country, but I found that it 
was practically worthless as a disinfectant. The claim has been made 
that sleeping-cars are thoroughly disinfected with formaldehyde. I 
have worked much with formaldehyde, and I think that my olfactory 
nerves can readily detect small quantities of this gas, and I may say 
that I have never ridden in a Pullman car that showed any evidence of 
recent disinfection with this substance. I doubt not that the form of 
disinfection is gone through with occasionally. Sheets are sprinkled 
with formaldehyde and hung up in the car. Now, so far as the dis- 
infection of the car is concerned, I believe this method to be practically 
worthless. 

I am perfectly willing to give the Pullman Company a few sug- 
gestions. The company should make the interiors of their cars per- 
fectly plain, all the carving and " gingerbread " work which now mar 
the average sleeping-car should be done away with. The surfaces 
should be perfectly plain. The floors should be of some non-absorbable 
material. The seats should be movable, and then the car can be 
scrubbed with a mop and whatever disinfectant is found most desirable 
can be used. I would also advise that the plush seats be done away 
with, and until that can be accomplished the seats now in use should 
be covered with washable linen and these covers should be removed at 
the end of every trip and disinfected. The blankets should be dis- 
infected outside of the cars. 

There is much room for improvement in the disinfection as well 
as in the proper ventilation of sleeping-cars. 

Mr. Edward T. Devine, New York: I would like to offer two 



AND PREVENTION OF TUBERCULOSIS 1 23 

suggestions. The first is that this association should have a standing 
committee on sanitation and transportation, with Dr. Vaughan as 
chairman. They should keep in touch with the railroad companies 
and should get up feasible, practical and sensible suggestions for the 
use of the companies. They might find it well for all states to have 
the Texas law. The second is that if it is true that railroads are 
financial institutions and that they will adopt suggestions, it is clearly 
our duty to create a demand for them. We should suggest the cover- 
ing of the blankets, and the seats, etc., and urge the necessity of these 
changes. The education of the public is the important point. We 
must increase the number of people who appreciate the fact that leather 
is better than plush. 

Dr. Chas. L. Minor, Asheville: I would be glad to second Mr. 
Devine's motion in reference to the Pullman car and railroad service. 
The men in the financial departments are at the head of the railroads 
and the railroad surgeons are unable to make any headway ; they can- 
not help themselves ; their suggestions are swept to one side in order 
to give a few more dollars to the stockholders. There is no more im- 
portant work for us to do than to look after this subject. The financier 
does not care for the public; he cares only for the money, and it is 
the duty of the public to take hold of the matter. We cannot get any- 
thing until we force it out of the companies. Dr. Vaughan should 
be in charge of the committee so that if possible the changes may be 
pushed through. 

Dr. F. M. Pottenger, Los Angeles: There is one transcontinental 
line, the Northern Pacific, that does have good sanitary laws and 
regulations. As to the third sheet now in use by the Pullman Com- 
pany, I have heard many people express themselves as heartily in 
favor of it. 

Dr. S. A. Knopf, New York: The Pullman Company should stop 
permitting the porters to dust off the passengers. Of course we know 
why the porters do it, but it is one of the worst dangers. Personally 
I usually g^ve the porter a quarter and ask him to leave me alone. 
Another important thing is in the spittoon. The openings are too 
small and they are not deep enough. They should have larger open- 
ings and should have something more in them than water. 

Dr. H. M. Bracken, St. Paul: The Pullman Company is open to 
criticism for waiting so long before having a sanitary inspector. As 
to the spittoon, it is not fit to use. The kind that is required in Austria 



124 NAT. ASS N FOR STUDY AND PREV. OF TUBERCULOSIS 

gives you some idea of what is needed. Some of the companies are 
introducing improvements. The representative of the Pennsylvania 
Railroad seems to think he has to be on the defensive, but his road 
is one of the best. I do not believe, as Dr. Hurty has said, that we 
are not just as cleanly in the cars as in our homes. I realize that 
disinfection of the cars is difficult to carry out, but it is a clean car 
that we want. I did not have time to read the Texas regulations, but 
there is one thing we need and that is for all states to work together. 

Dr. J. W. Kime, Fort Dodge, Iowa : I did not hear all of this dis- 
cussion, but I believe in fair play. The Pullman Company, the Penn- 
sylvania Railroad Company, the Atchison, Topeka and Santa Fe Rail- 
road Company, and the Metropolitan Street Railway Company of New 
York have shown commendable enterprise in sending their repre- 
sentatives here to commune with this assembly. I believe that meas- 
ures of this kind are entitled to a vote of thanks from this assembly, 
especially for their representation upon this question, and I would 
move that a vote of thanks be tendered to them. 

Dr. Chas. L. Minor of Asheville seconded and it was unanimously 
carried. 



PATHOLOGICAL 
AND BACTERIOLOGICAL SECTION 

Chairman 
MAZYCK P. RAVENEL, M. D. 

Philadelphia 
Secretary 

D. J. McCarthy, m. d. 

Philadelphia 



PATHOLOGICAL 
AND BACTERIOLOGICAL SECTION 



THE THERAPEUTIC VALUE OF MARMOREK'S 
ANTI-TUBERCULAR SERUM 



By Arthur J. Richer, M. D. 
Montreal 



Specific sera for the cure of tuberculosis have during the last ten 
years occupied the attention of bacteriologists and therapeutists alike. 

The last product of the kind, Marmorek's anti-tubercular serum, 
is really worthy of more than passing notice. Of the seven advanced 
cases (some hopeless) which I reported in September 1904,^ four have 
kept up to their improved condition. Since then I have submitted nine 
incipient tubercular patients (pulmonary) and the results have been 
uniformly good. In some instances improvement was very marked 
within forty-eight (48) hours, accompanied by corresponding modifi- 
cations in the physical signs. Among the patients of the incipient class 
thus treated in no single instance did any untoward symptom become 
manifest. Upon the healthy subject the serum remains without effect. 
I have inoculated as much as ten c.c. (in myself) at one sitting without 
being in any way inconvenienced. 

In detail I will describe but one case, my first incipient : a girl of 
twenty whose personal antecedents were negative except for an attack 
of measles at five (5) and whooping cough at six (6) years of age. 

^Montreal Medical Journal, Sept., 1904. 

127 



128 NATIONAL ASSOCIATION FOR THE STUDY 

Family history tells us that mother died of pulmonary tuberculosis four 
years ago after an illness of 23^ years. Father living and well. One 
brother died of tubercular meningitis eight years ago. Four younger 
sisters living and well. 

This patient confessed impaired vitality about six months previous 
to my seeing her and when examined she complained of complete 
anorexia, in fact a perfect disgust for food, dyspnoea upon slightest 
exertion accompanied by a dry cough and occasional night sweats with 
some degree of wasting. 

When examined (July 9, 1904) she had a pulse of 110 and an 
afternoon temperature of loi. The right lower lobe was the seat of 
complete consolidation both back and front. Two days later she entered 
the hospital (private ward) and was kept in bed under supervision for 
three days without any change taking place in the symptoms ; she was 
then given 5 c.c. of serum. The next afternoon the temperature had 
come down to 99.3 ; she was given another 5 c.c. which brought down 
temperature to 98.3, after which the afternoon rise never exceeded 
normal. The pulse was visibly affected, coming down to 80 within five 
days, while the appetite at once became voracious. Patient was allowed 
out of bed ten days after first inoculation and was sent to the country 
remaining away two months only, during which time she received four 
inoculations of serum of 5 c.c. each. 

When examined again on September 30th, nothing but a small 
area of impaired resonance could be detected at extreme base behind. 
She has been examined a number of times since and the lungs are now 
clear, having remained so since November ist, 1904. The results in 
the remaining eight patients were quite as good, but as they were 
treated more recently cannot be pronounced upon. A significant fact, 
however, is that in all incipients thus treated, the effect of the serum 
seems to have been truly specific, not one patient failing to react favor- 
ably. 

Jacquerod,^ Arthur Latham,'^ de Rotschild & Brunier,^ Montalti,* 
Klein & Jacobsohn,^ Schwartz,^ Frey,'^ Lemieux and myself, have re- 

^ Jacquerod, Revue de Medecine, Mai, 1904. 

* Arthur Latham, Lancet, April 9th, 1904. 

'De Rotschild & Brunier, Progres Medical, 23 Avril, 1904. 

* Montalti, Progres Medical, 30 Avril, 1904. 

' Klein & Jacobsohn, Bulletin General de Therapeutique, 30 Juillet, 8 et 
15 Aout, 1904. 

'Schwartz, Allg. Med. Central Zeitung, No. 41, 1904. 
^ Frey, MUnch. Med. Wochen., No. 44, 1904. 



AND PREVENTION OF TUBERCULOSIS 1 29 

ported upon quite a number of cases, but in all instances these were 
cither advanced, chronic or quite hopeless, yet with a good percentage 
of successes. 

The method of giving the inoculation in series of six or ten with 
periods of rest has not seemed to me to be quite rational. The quantity 
of toxine elaborated by the tubercle bacillus is small and the elaboration 
is very slow; why, then, should large quantities of anti-toxine be 
given ? 

Usually I inoculate 10 c.c. during the course of three days giving 
2 c.c. first day and 4 c.c. each subsequent day ; then I allow a period of 
rest of at least ten days, sometimes fifteen, proceeding in the same way 
until 50 c.c. have been injected. After examination of patient, if results 
are good, I believe it wise to continue the inoculations every month 
(5 c.c.) for four or five months, in order to keep up the passive immu- 
nity conferred by the anti-toxine. 



THE NATURAL AND ARTIFICIAL PROTECTION 
OF MAN AGAINST TUBERCULOSIS 

By Dr. F. Figari 
Genoa 

(From the Institute for the Study and Cure of Tuberculosis and other 
Infectious Diseases, Genoa.) 



The faculty which the bacillus of Koch has of producing an infec- 
tious disease depends on many and various factors, which are repre- 
sented on one hand by the property the said bacillus has of multiplying 
and diffusing itself throughout the organism which shelters it, and of 
its faculty of producing toxine, which has local effect at the point of 
development and generally throughout the entire organism; on the 
other, by the degree of resistance, congenital or acquired, which the 
organic cells present to the bacillus. 

Very numerous are the ways by which this widely spread bacillus 
daily menaces the public health, and we must not have too much faith 
in the protection which the integrity of our teguments opposes to it; 
the skin and the mucous membranes show continually small cracks 
which may become ways of entrance. The tonsils by their anatomical 
structure are receptacles for the bacilli, which, in contact with the lym- 
phatic elements, have easy access to the interior. 

In the lungs, notwithstanding that the " Epitelie Vibratili " (Cili- 
ated Epithelium) with its movements is the same tissue, it opposes a 
certain resistance to the invasion of the bacillus. Also these germs in- 
troduced by respiration into the alveoli are easily absorbed by the lym- 
phatic currents of the lungs, and are transported to the lymphatic 
glands, and that without any previous grave lesions of the alveoli. 

The normal secretion of the stomach has no appreciable influence 
on the attenuation of the bacillus of tuberculosis, which, entering the 
stomach with the food, can pass unaltered into the intestines, where, 
whether by the great number of lymphatic glands, or by the wealth of 

130 



NAT. ASS N FOR STUDY AND PREV. OF TUBERCULOSIS I3I 

liquid lymphatic elements, it finds more than anywhere else the most 
favorable conditions for the development of the disease. 

The organism with its teguments does not offer sufficient pro- 
tection against tubercular infection, and we have seen that there are 
many easy ways of entrance at the disposition of this terrible germ, 
which, widely diffused throughout nature, comes in daily contact with 
our skin. We absorb it into our lungs with the air we breathe ; we in- 
troduce it into our stomach with our food, yet notwithstanding the 
many and easy ways of infection, not every person becomes tuberculous, 
which proves that the body in spite of the insufficient means of resist- 
ance of the teguments, possesses in its intimate nature specific defen- 
sive energies which prevent the bacillus from penetrating into the 
interior and from multiplying, and which neutralizes the action of its 
secretions, — substances anti-bacterial and substances anti-toxic ; sub- 
stances, which acting together constitute that phenomenon called Im- 
munity. 

If, however, an organism endowed with these specific substances, 
is exempt from a tubercular infection of medium violence, it will not be 
so from an ultra-violent infection ; and also it might, at certain moments, 
if the harmonious functions of its tissues are interrupted, find itself an 
easy prey to these bacilli, hence the great value of prophylactic rules, 
and of the hygiene of living and of alimentation to protect it from 
tuberculosis. 

If we think, however, of the immense number of tuberculous people 
who continually sow abroad the infectious virus by means of expecto- 
ration, and of the difficulties of the financial condition with which the 
greater number of people are confronted, we find ourselves wholly 
unable to put these individuals in good conditions of life and alimenta- 
tion. 

Hygiene, food, and air, potent and useful means of defense against 
tubercular infection, are not, because of the actual conditions of society, 
rigorously applicable, and so we cannot depend absolutely on them in 
the struggle against tuberculosis. With time certainly, with the dif- 
fusion among the masses of hygienic rules, and with the financial 
amelioration of certain social classes, these defensive means will 
acquire greater utility. For the present we must depend on the or- 
ganism. 

The antitoxines, the antibodies elaborated in the cells of our tissues, 
are the best means of protection against tubercular infection, and their 



132 NATIONAL ASSOCIATION FOR THE STUDY 

presence in a great number of individuals is perhaps the only cause 
why, with such a diffusion of virus, a great many people do not become 
a prey to the bacillus of Koch. 

To engraft these means of protection into the organism is, at the 
present, the surest means of fighting against tuberculosis, and the 
easiest method, which is now at our disposal. 

The bacillus of Koch penetrates into the organism, fixes itself 
upon an organ, where it develops and produces its special toxine, 
which has a local action, and also an action on the distant organs, dis- 
turbing and preventing the normal functions of the tissues, depriving 
them of their vitality, and so predisposing them to excessive infection 
of the same, or even of a different nature. Not only the toxines, but 
also the dead bodies of the bacilli excite a like deleterious action in the 
tissues. 

It is to the neutralization of the action of this toxine that Mara- 
gliano first turned his attention by the introduction in therapeutics of 
a serum possessed of a high antitoxic value, obtaining as a secondary 
result also a bactericidal action, since the cellular elements having be- 
come insensible to the deleterious action of the bacterial toxines by 
means of these antitoxines, artificially introduced, can exercise the 
normal bactericidal energy, which is in all the tissues. 

It is by this means that Maragliano in 1894 succeeded in rendering 
animals immune against experimental tuberculosis and combating vigor- 
ously human tuberculosis, if in a curable condition. 

Maragliano afterward thought that besides these substances ca- 
pable of neutralizing the bacterial toxines, one could inoculate with 
substances directly " bactericidal." One would have in the result of 
these means of defense that force of resistance which is called im- 
munity. 

Following his advice, and under his guidance, I, with Marzagalli, 
sought to obtain sera strongly bactericidal, injecting into animals the 
living tubercle bacilli, and we have observed that by making subcuta- 
neous injections of this pulp of bacilli into rabbits, goats and cows, 
these animals produce in their serum large quantities of substances 
which combat the bacillus of tuberculosis. These sera are capable, 
in vitro, of preventing the bacillus of tuberculosis. 

In vivo, if one injects into experimental animals, rabbits, guinea- 
pigs, the bacillus of tuberculosis, supplemented by this serum, the 
animals do not contract the disease; while equal doses of the same 



AND PREVENTION OF TUBERCULOSIS 1 33 

bacillus, supplemented with physiological serum, give, in the same 
kind of animals, acute, mortal tuberculosis. (Marzagalli, Figari, 
Annali Maragliano, No. i.) 

The sera so prepared have a high protective and " immunizing " 
power. 

Animals of different species, treated prophylactically with these 
sera become refractory to an excessive infection of tuberculosis by 
endovenous injection certainly fatal to animals not so treated. (Figari, 
Annali, Maragliano, No. i.) 

Hypodermic injections of this serum have a high specific thera- 
peutic value in the tuberculosis of man and animals. Monkeys, become 
tuberculous normally, or by direct infection, are completely cured by it. 
(Marzagalli, Figari, Annali Maragliano, No. 2; Riforma Medico, 
Anno 1905, No. 10.) 

Doctor Ricci has had most favorable results in patients affected 
with lymphatic tuberculosis, and with pulmonary tuberculosis. (XIV 
Italian Medical Congress, Gaszetta delle Cliniche e degli Ospedali, 
Anno 1905, No. 31.) 

Doctor Ghedini has experimented on the action of these sera on 
experimental tuberculosis of the joints and has found that local injec- 
tions are capable of making the disease, already in a very advanced 
state, regress, even to a complete cure. {Gazsetta delle Cliniche e degli 
Ospedali, Anno 1905, No. 16.) 

Not only in the serum but in the corpuscles of the blood (Figari, 
Gazzetta Ospedale Cliniche, 1903, No. 77.), and in the milk drawn 
from these animals (Figari, Annali Maragliano, Nos. 2, 3.) one finds 
these specific substances, which, administered by the mouth (Figari, 
Annali Marigliano, Nos. 2, 3.), become absorbed in the digestive tract 
and are capable of favorably influencing a tubercular infection in man, 
even to complete cure. (Figari, Morgagni, 1904, No. 3; Ricci, Gaz- 
zetta Ospedale Cliniche, 1904, No. 99; Niccolini, ibidem, Anno 1904, 
No. 124; Ceci, ibidem, Anno 1905, No. 28.) 

In animals, young or old, in healthy children or adults, admin- 
istered by the mouth, they become absorbed in the digestive tube and 
excite in the serum of these individuals the formation of specific de- 
fensive means in such quantities that all the animals experimented upon 
when infected in the veins by doses of tubercle bacilli capable of killing 
in a very short time animals not so treated, victoriously overcome the 
infection. 



134 NATIONAL ASSOCIATION FOR THE STUDY 

As the result of these experiments, confirmed by other observers, 
whom for brevity, I omit to quote, is shown the possibiHty we now 
possess of exciting in individuals who are poor, or absolutely without 
means, the formation of a natural protection against tuberculosis; a 
natural protection which we can produce by subcutaneous injections of 
serum obtained from animals treated with pulp of bacilli and with 
bacillary toxins; or by administering by the mouth, milk or blood 
obtained from the same animals. Whichever be the means adopted, 
the results are about equal. By subcutaneous administration, the ef- 
fects are more rapid; though in administration by the mouth, these 
defensive energies very soon begin to show themselves in the serum. 

In order to administer these specific substances to human beings 
by the mouth I, and the already mentioned experimenters, have used a 
preparation of the Institute for the Study and Cure of Tuberculosis 
much appreciated by physicians. This preparation called " Emoan- 
titossina Sofos " is only a solution of antitoxic and bactericidal sub- 
stances which can be preserved indefinitely, and which by the addition 
of aromatic substances excite the gastric functions and become very 
agreeable to the palate. 

Having thus accepted the possibility of creating an immunity 
against tuberculosis, by administering specific defensive substances, 
I wanted to see if it would be possible to produce an active immunity 
in laboratory animals by injecting directly into the animals which I 
wished to render immune attenuated bacilli or bacillary extracts. 

This second method of " immunization " is called by almost all 
the authors " active immunization," while the method first used is called 
" passive immunization." For convenience of diction one may use these 
expressions, though biologically speaking, this distinction does not 
exist, because, also in the so-called passive immunity, it is the organism 
which actively participates in the formation of defensive substances 
under the exciting and stimulating action of the antitoxins and of the 
bactericidal substances, which we introduce. 

As animals of experiment I used six monkeys. In four of these 
monkeys I injected into the veins, in emulsions of physiological serum, 
a minimum quantity of very slightly virulent tubercle bacilli. 

These monkeys did not show any local reactions whatever, nor 
general derangement. They had no fever nor did they lose weight. 
Three months after these injections in order to ascertain whether these 
endovenous injections of bacilli, which had proved innocuous, had had 



AND PREVENTION OF TUBERCULOSIS 1 35 

a preventive and vaccinating action, I injected into the veins of these 
four monkeys, and also into the other two, an emulsion of the most 
virulent tubercle bacilli. All the monkeys contracted an acute tuber- 
cular infection which brought them rapidly to death. The monkeys 
treated with the preventive injections died first, and then the others. At 
the autopsy all of them presented the characteristic lesions of acute 
tuberculosis. 

Also rabbits which I attempted to render immune with subcuta- 
neous injections of attenuated bacilli, which were incapable of pro- 
ducing infection and which did not provoke any reaction, local or 
general, showed no resistance whatever to experimental infection. 
Rabbits treated preventively, as well as others not so treated, contracted 
a diffused tuberculosis which killed them. 

These experiments did not certainly authorize us to reject com- 
pletely this method of rendering immune. It may be that new methods 
and great experience will show some utility in it. I, for the moment 
must say, that I have obtained no immunizing effect on monkeys or on 
rabbits. On the contrary, according to the results of my experience, 
these injections had an effect predisposing to infection. 

In conclusion I can now affirm that if we have not succeeded in 
immunizing animals against tuberculosis with living cultures, it is 
experimentally ascertained that we can produce this immunity by inject- 
ing subcutaneously, or administering by the mouth, specific substances 
taken from animals treated for that purpose. As serum, blood, and 
milk have this property, certainly the flesh of these animals will possess 
it; and at the present time these are the sole means on which we can 
count for the cure of tuberculosis, by rendering immune the children of 
tuberculous people and individuals who are predisposed to it. It is only 
by widely spreading practised preventive immunization that we can 
hope to stop the spread of tuberculosis. 



THE SERUM DIAGNOSIS OF TUBERCULOSIS 

By Hugh M. Kinghorn, B, A., M. D. 

Saranac Lake 
(From the Saranac Lake Laboratory.) 



After it was found that the serum of animals that had been in- 
jected with bacteria possessed agglutinating power over the same 
bacteria, and that the serum of man agglutinates typhoid, cholera, and 
plague if he suffers from typhoid, cholera, and plague, it was suggested 
that the blood of tuberculous individuals would agglutinate tubercle 
bacilli. But tubercle bacilli offer a great obstacle to such investigation, 
because they form in their cultures compact masses, which are already 
to some extent in an agglutinated condition. 

Arloing overcame this difficulty by cultivating the bacilli for a 
considerable time on potatoes, till the cultures obtained a smooth ap- 
pearance. He then transferred them to beef broth with 6% glycerine. 
In this way he finally obtained a culture that grew evenly distributed 
throughout the liquid, that is to say, the culture became homogeneous. 

Together with Paul Courmont he found that homogeneous tuber- 
culous cultures can be agglutinated by the serum of several kinds of 
animals, when these animals are inoculated by tuberculin or by at- 
tenuated cultures of tubercle bacilli. They also found that this normal 
blood serum of certain animals is able to agglutinate the homogeneous 
cultures, but with much less activity than when these animals are in- 
fected with the tubercle bacillus, or injected with its products. 

A sufficient number of tests were made on human beings to con- 
vince them that the serum agglutination can be used in the diagnosis 
of tuberculosis, and they regard the test of equal value to Koch's 
tuberculin. 

Many scientists of various nationalities have made publications 
absolutely confirmative and based on a large number of cases. Other 
investigators, and particularly in Germany, have obtained very different 
results. At the present time, however, the serum agglutination test 
for tuberculosis is still in doubt. 

136 



NAT. ASS N FOR STUDY AND PREV. OF TUBERCULOSIS 1 37 

The chief objections to the test are due to the following facts, 
namely that the serums of quite a number of healthy individuals and 
of patients with other deseases are able to agglutinate homogeneous 
tuberculous cultures, and also that in some patients with well marked 
symptoms of tuberculosis in the incipient or advanced stages the re- 
action is wanting. 

In spite of these contradictory results Arloing and Courmont still 
firmly maintain that an individual whose blood serum agglutinates 
a homogeneous tuberculous culture at i to 5 is tuberculous, and if at 
I to 10, he is tuberculous without a doubt ; and that the serum reaction 
reaches its highest grade of intensity when the lesions are slight. 

The contradictory results are partly due to the difference in the 
cases tested. The general condition of the patient, and the stage and 
severity of the disease have great influence on the agglutination. The 
reaction can also vary during the course of the disease. In 5 far ad- 
vanced cases, 4 fail to react, while in 38 patients which included 
healed, incipient, and advanced cases, 5 failed to react. In giving 
percentages, therefore, it seems fair to exclude the far advanced cases 
in which the diagnosis is plain without other means of help. 

The chief reason for the difference in the results rests with the 
test culture used. In spite of the clear directions given by Arloing 
and Courmont, the preparation of the culture is extremely difficult, 
and it is very hard always to have on hand a culture at standard 
strength. In order to avoid this difficulty Koch and Romberg have 
modified the method of Arloing and Courmont, and used emulsions 
of dead bacilli instead of living homogeneous cultures. These emul- 
sions are much more easily prepared, and the results are much more 
uniform. 

In the following tests the "A" homogeneous culture of Arloing 
and Courmont was the one used. It was kindly g^ven by Dr. Paul 
Courmont during his recent visit to America. The tests were all 
made with cultures which were standardized as accurately as possible. 
Where there was any doubt that the culture was not at standard 
strength, the test was not counted. 

The culture was grown in the following medium: 

Peptone (Witte) 20 

Sodium chloride 10 

Glycerine 40 

Water 1000 



138 NATIONAL ASSOCIATION FOR THE STUDY 

This was neutralized with normal soda solution. This is the 
formula given by Dr. Courmont with the exception that Witte's pep- 
tone was used instead of Dufresne's (French peptone). The standard 
serum was obtained from a normal sheep, whose serum was found to 
constantly agglutinate at 1-25. Clear fresh human serum was used 
to make the tests. It was obtained either from the lobe of the ear or 
from a vein in the arm. 

With each serum, mixtures of different strengths were prepared 
at I to 5, I to 10, I to 15, and so on; that is, to one drop of serum 
five drops of culture are added, etc. Or else it was done by adding to 
0.2 of serum .... 0.8 of culture (1-5 ) 
0.1 of serum .... 0.9 of culture (i-io) 
0.06 of serum .... 0.94 of culture (1-15) 
0.04 of serum .... 0.96 of culture (1-25), etc. 

Comparative tests were made with these methods, and as they 
were the same, the latter one was used. The former, however, is 
simpler, and can be used with better advantage when one has a small 
amount of serum. 

When agglutination took place in a dilution of i to 5 the reaction 
was considered positive. The time limit given to the reaction was 5 
hours, not more, A well developed, actively growing culture of a 
month's growth was removed from the incubator and placed in the 
ice chest. It was used for a month, or as long as it was agglutinated 
by the standard serum up to the proper dilution. The necessary 
quantities of culture were taken and diluted with normal salt solution 
(0.8 per cent) until the mixture became slightly milky. 

Agglutination was observed by the naked eye up to 5 hours. 
Results were considered positive only in those tubes which showed 
well marked flocculi easily visible to the eye, and with subsequent 
sedimentation and clearing. 

Results 

One hundred and twenty four serums were tested. I found later, 
however, that the culture was not at standard strength in 62 of these, 
and they were excluded. Sixty-two, therefore, remain to be reported on. 

Of these ^2 cases, 43 were tuberculous, 12 were apparently in 
robust health, and 7 were more or less suspicious as having tuber- 
culous disease. In these 7 there was no positive evidence of tuber- 
culosis, and they were not tested with tuberculin. 



AND PREVENTION OF TUBERCULOSIS 1 39 

Of the 43 tuberculous cases 34 reacted, 9 failed 

• Of the 12 healthy cases 9 reacted, 3 failed 

Of the 7 suspicious cases 7 reacted, o failed. 

Of the tuberculous cases there were: 

2 healed patients i reacted, i failed 

3 patients that reacted to the tuberculin test 3 reacted 

9 incipient cases 8 reacted, i failed 

24 advanced cases 21 reacted, 3 failed 

5 far advanced cases i reacted, 4 failed. 

It is thus seen that nearly all the more favorable cases gave 
positive reaction (i.e. 86.8%), and that only one of 5 far advanced 
cases reacted. 

Conclusions. 

(i) In far advanced cases with very extensive or virulent lesions 
and with high fever the serum reaction is generally absent. 

(2) The reaction seems to appear most often with the most favor- 
able cases. 

(3) A certain number of favorable cases with well marked sig^s 
of disease fail to show any agglutination. 

(4) Nine out of 12 persons in robust health reacted to the test. 
Six of the 9 were in close contact with tuberculous patients. 

(5) In the tuberculous cases the average agglutinating power 
was I to 10; in the healthy cases the average agglutinating power 
was I to 23. 

(6) Up to the present time I do not rely on the serum test as 
being a sure and reliable one for the presence or absence of tuberculosis. 



STUDIES IN AGGLUTINATION 

By Mazyck p. Ravenel, M. D., and H. R. M. Landis, M. D. 

Philadelphia 

(From the Laboratory of the Henry Phipps Institute.) 



The present studies in agglutination were instituted for the pur- 
pose of determining whether the reaction was of any prognostic 
significance in tuberculosis and also to determine whether the resist- 
ance of the individual was increased by the hygienic and dietetic means 
now employed. 

It is not necessary at the present time to discuss the various 
hypotheses concerning the phenomenon of agglutination. It is pretty 
generally accepted that while the phenomenon is not always present 
in the blood of immunized animals, when it is present, it is an indica- 
tion that the blood of such an animal has a detrimental effect on the 
growth and vitality of the specific micro-organism ; and thus in some 
way allied with the process of immunization. It is also assumed that 
the higher the agglutinating power the greater is the degree of im- 
munization. 

From a limited experience with the reaction as a diagnostic agent 
we do not believe that it is available, as we obtained it in healthy in- 
dividuals. 

The cases we have studied may be divided into three groups: 
(i) Those in which Maragliano's serum was administered; (2) those 
with advanced disease, most of them in the terminal stages of the dis- 
ease; and (3) those under treatment at the White Haven Sanatorium 
from four months to one year. This group consist of incipient cases 
with two exceptions, one being moderately advanced, the other far 
advanced. 

The five cases in which Maragliano's serum was administered 
were all suffering from advanced disease and had ceased to improve 
under the usual dietetic and hygienic measures. 

140 



NAT. ASS N FOR STUDY AND PREV. OF TUBERCULOSIS I4I 

While admitting that they were cases unsuitable for the serum, they 
were selected for the purpose of seeing what results could be obtained 
by its use. Three of these cases were confined to their beds ; two were 
ambulant cases. In the two ambulant cases the test was made after 
the first few injections and again repeated after several months had 
elapsed. In one it remained unchanged ; in the other it increased from 
i-io up to 1-20. 

The three bed cases, all of them with extensive disease, were 
tested after a number of injections of serum had been made. Two 
agglutinated 1-30, although the diazo-reaction was present ; the other 
agglutinated 1-50. 

In fifty-nine cases with advanced disease, from the wards of the 
Phipps Institute, the following results were obtained: 

30 agglutinated i-io 

18 agglutinated 1-15 

I agglutinated 1-25 

I agglutinated 1-30 

In striking contrast to these cases are the cases from the White 
Haven Sanatorium. Of nineteen cases in which the test was made 
the following results were obtained: 

I agglutinated i-io 

I agglutinated 1-15 

6 agglutinated 1-20 

9 agglutinated 1-25 

I agglutinated 1-30 

Forty-eight of fifty-nine advanced cases did not agglutinate above 
I- 1 5, while sixteen of nineteen cases at the Sanatorium, under treat- 
ment from four months to one year, agglutinated at 1-20 or higher. 

• It is, furthermore, of interest to note that the one incipient case 
which agglutinated at i-io only has severe constitutional manifesta- 
tions with slight pulmonary involvement. A favorable outcome in 
this case is doubtful irrespective of the agglutination test. 

The diazo-reaction was tested for in forty-six of the fifty-nine 
advanced cases ; in thirteen it was present, in thirty-three absent. The 
diazo-reaction was never present when the agglutination was above 
1-15, on the other hand it was absent in twenty-six instances when the 
agglutination was 1-15 or lower. Eight of the fifty-nine advanced 



142 NAT. ASS N FOR STUDY AND PREV. OF TUBERCULOSIS 

cases have died since these observations were made; only one of the 
eight agglutinated up to 1-20. 

The technique employed was as follows: 

From 5 c.c. to 10 c.c. of blood was drawn from a vein at the 
bend of the elbow. The blood was allowed to stand for twenty-four 
hours, when the serum was drawn off and dilutions made with a 
homogeneous culture of tubercle bacillus in proportions from 1-5 
up to i-ioo. 

The homogeneous culture was grown from twelve to fourteen 
days in 5% glycerine bouillon, then formalin was added in the pro- 
portion of i-iooo. The tubes containing the culture and serum were 
observed every two or three hours but the final reading was made at 
the end of twenty-four hours. A positive result consisted of a clearing 
of the supernatant fluid or the agglutination of small whitish clumps, 
usually at the bottom, but occasionally along the sides of the tube. 

From this study we believe that the following conclusions may 
be drawn: 

1. That the agglutination test is not available for diagnostic 
purposes. 

2. The more advanced the disease the lower is the agglutinating 
power. 

3. A low agglutination is of unfavorable prognostic significance. 

4. That cases under favorable conditions as at a sanatorium, have 
the agglutinating power distinctly increased. 



STUDIES ON IMMUNITY IN TUBERCULOSIS 

Part I 

THE PROPERTIES OF THE SERUM OF IMMUNIZED RABBITS 

By E. R. Baldwin^ M. D., H. M. Kinghorn, M. D., and 
A. H. Allen, M. D. 

Saranac Lake, N. Y. 



The following experiments were undertaken largely as a con- 
tinuation of the work presented by Dr. Trudeau in 1903 before the 
Association of American Physicians.^ It was desired to obtain if pos- 
sible a closer insight into the mechanism of the specifically acquired 
resistance to a virulent human tuberculous infection produced in rab- 
bits by previous intravenous inoculation with bacilli of weak virulence. 

Briefly described, the observations previously made were that 
an intense and prolonged inflammatory reaction, both general and 
local, occurred in the vaccinated animals immediately following the 
virulent inoculation. This was not noted in the controls. Gradually 
this tuberculin-like reaction subsided and in many favorable cases the 
ultimate result was an almost complete absorption of the tuberculous 
foci and disappearance of the bacilli, while in the meantime the con- 
trols became progressively worse until a condition of chronic tuber- 
culosis ensued. 

The importance of an intimate knowledge of this immunity is at 
once obvious to us. It might explain some phases of the clinical course 
of human tuberculosis in its relapses and pneumonic forms, and even 
furnish new view-points for a rational therapy. Furthermore as this 
vaccination has already been found useful in the bovine race, one 
may not be skeptical of its possibilities in human application. 

The first step naturally suggested was to follow from day to day 
the different stages of the reaction in comparison with control animals 

* Transactions of Association of American Physicians, Vol. XVIII, 1903. 

143 



144 NATIONAL ASSOCIATION FOR THE STUDY 

killed simultaneously. For this purpose 23 Belgian hares were first 
selected as nearly the same color and size as possible, and 13 were vac- 
cinated by the inoculation of .0001 gm. from a broth culture (R i 
human) intravenously. No apparent loss of health usually follows 
this dose unless the animals are already the subjects of some other 
infection such as coccidiosis, or septicemia (snuffles). Of this series 
one died from the effects of fighting. The virulent inoculation fol- 
lowed in two months. Two c.c. (:= 0.002359 g.) of virulent human 
(" H 33 ") from 9 days' serum cultures was given in the same way 
to II vaccinated and 10 controls, one of the former being reserved 
without inoculation. The animals were etherized and bled to death in 
pairs, from the ist to the 30th day at intervals of several days. Later 
a second lot of 30 hares and rabbits were vaccinated and 25 inoculated 
in the same manner together with 20 controls. This series was killed 
from the 14th to the 6ist day so that a fairly complete review of the 
pathological processes was obtained (see the paper by Dr. J. L. 
Nichols). In addition to the above a further series of 5 pairs was 
used, more especially for the study of the serum reactions. 

Daily observations of the temperature for a month after the viru- 
lent inoculation were made on 10 pairs of the first series, the result 
of which indicated an average higher temperature for the vaccinated 
animals during the first 10 days, but higher for the controls for the 
second 10 days, after which both subsided; thus it coincided with the 
course of the inflammatory reaction as described in the pathological 
report. 

Agglutination Tests. — The examination of the serums was 
made either on the day of the bleeding or within 24 hours. 

Various emulsions and extracts of tubercle bacilli were employed 
to test their agglutinating and precipitating powers, but the preparation 
employed mostly was an emulsion of pulverized bacilli as described by 
Koch, but without the addition of phenol. 

The lack of uniformity in successive emulsions of the homoge- 
neous culture of Courmont made the result with this method useless 
for comparison. Moreover, the serums showing most activity in sedi- 
menting Koch's emulsion frequently failed to agglutinate the Cour- 
mont cultures and vice versa. 

The pulverized bacillus emulsion was prepared by diluting one part of 
a i-iooo Koch emulsion to 3 volumes with 0.85% NaCI, which made a weak 
opalescence. The tests were made in dilutions of i in 5; i-io; 1-15; 1-20; or 
higher when the serum proved active. Each tube contained a total volume of 



AND PREVENTION OF TUBERCULOSIS 1 45 

I c.c. and a small drop of toluol. The readings were taken after 24 hours in 
the incubator and only sedimentation with clearing was regarded as a positive 
reaction. 

Weak emulsions of the homogeneous culture " A " obtained from Prof. 
Courmont as well as one of our own (" k ") were made by diluting the one 
month broth cultures about 4 times with 0.85% NaCl. Observations were 
taken after 2 and 5 hours, the tubes being kept at room temperature. 

The results of precipitation tests with filtered extracts of tubercle 

bacilli were uniformly negative. 

Normal saline NaCl 0.85% and NaHCO» 0.05% extract* of washed broth 
cultures were prepared by digesting the bacilli for 24 hours at 45° C. and filtering 
through the Berkfeld bougie. 

The sedimentation produced in Koch's emulsion, was, however, 
quite marked in most of the vaccinated serums from the 3rd to the 
30th day after the virulent inoculation, reaching a maximum of i to 
50 dilution in 2 serums and apparently higher and more constant be- 
tween the 5th and 12th days. All were negative before inoculation and 
during the first 2 days, and after the 30th day following inoculation. 
Only 9 controls out of 26 gave any agglutinations, the highest being 
I in 20 on the 9th day. 

A curious fact may here be noted in passing, that of the 9 controls 
reacting positively, 6 were found to have more or less coccidiosis of 
the liver and revealed very slight and unprogressive tuberculous 
lesions.^ Because of the complications these animals may be excluded 
in comparison with the race, and in general it may be stated that the 
controls were negative to the Koch agglutination test, although more 
frequently positive to the Courmont test. It would appear that the 
agglutinin' in the coccidiosis animals was less specific or a so-called 
" partial agglutinin " since its genesis probably depended upon the 
presence of the coccidiosis. This view is strengthened by the fact that no 
congestion was evident about the tubercles in th^se animals.^ On com- 
parison of the lung sections with the results of the serum tests we noted 
a correspondence of the stronger serum reactions with the more in- 
tense and extensive inflammatory appearances in the vaccinated 
animals. 

*This apparent insusceptibility or restraining influence upon tuberculosis 
in animals suffering from coccidiosis has often been noted by us, and has 
recently been mentioned by Libbertz and Ruppel in connection with other 
diseases in guinea pigs. Such animals appear to emaciate and die with but 
few apparent tuberculqus foci but often reveal extensive atrophy of the liver. 
— Deutsch med. Wochen., No. 4, Jan. 26th, 1905. 



146 NATIONAL ASSOCIATION FOR THE STUDY 

The significance of this undoubted development of agglutinin in 
the vaccinated animals far in excess of the controls is obvious as an 
evidence of a specific reaction-product. 

Whether we must also regard it as having some important func- 
tion in combating the infection is less certain at present. 

Phagocytosis. — The publication of Wright and Douglas' ^ 
work on the so-called " opsonin " in the tuberculosis serums naturally 
gave us the incentive to study the phagocytosis of the tubercle bacilli 
as influenced by the serum of immunized and control rabbits before and 
after inoculation. According to Wright and Douglas, who worked ex- 
clusively with human serums, an increase of the number of living or 
dead tubercle bacilli taken up by polynuclear leucocytes could be dem- 
onstrated, — by counting the bacilli according to Leishman's method, 
in the stained specimens ; — where the patient was undergoing a suc- 
cessful tuberculin treatment. 

The technique was somewhat lengthy and difficult and we found 
the rabbit's blood less adapted to the process than the human. After 
numerous trials we came to the conclusion that this method of deter- 
mining comparatively the opsonic power of serum was of little value 
in rabbits unless considerable differences were found in the strength 
of the serums. When the serums were of nearly the same or even 
moderately variable in strength, the counts were very wide in their 
variation. The above tests were made with 20 animals of the second 
series. 

The method of Leishman was first tried with blood taken directly from 
the ear vein during life and incubated 15 min. at 38.5° C. in a moist chamber 
on slides, with an equal volume of t. be. emulsion. The smears were then 
immediately dried and fixed, stained with aniline fuchsin 15 min. at 38° ; de- 
colorized with acid alcohol (0.5 %HC1; alcohol 50%) and stained with Wright's 
blood stain. Counts of the t. be. in 20 to 80 polynuclear leucocytes were then 
made and averaged. 

When the animals were killed the serum method was employed as 
described by Wright (3) using washed leucocytes obtained sometimes from 
healthy rabbits, but frequently from one of the inoculated animals. Two 
volumes of leucocytes suspended in normal NaCl, two volumes of centrifu- 
galized serum and one of a standard emulsion of t. be. in 0.1% NaCl were 
measured in eopillary pipettes and incubated 20 min. at 40° C. The greatest 
difficulty was experienced in preparing uniform emulsions of t. be. on suc- 
cessive days. The most satisfactory method was found to be the use of homo- 
geneous cultures grown on potato 8 days, sterilized by boiling the entire tubes, 
and taking a large standard loopful of the moist growth which was rubbed 

^Lancet, Oct. 24th, 1904. 



AND PREVENTION OF TUBERCULOSIS 1 47 

in 1.5 c.c. 0.1% NaCl and centrifugalized 15 min. in small tubes. These 
emulsions were generally free from clumps ; others were not, nor could the 
emulsion be used on successive days even if stirred up and re-centrifugalized 
without weakening it and thus making any comparison from day to day useless. 
At the best the spontaneous clumping of the emulsion and the varying 
agglutinating powers of the serum made the counts of doubtful value for 
comparison on the same day. An inevitable variability in the number of the 
leucocytes present and active is another source of fallacy. 

By modifying the technique somewhat we were able to study the 
opsonic power of the serum of 5 immunized and 4 control animals 
whose blood was taken almost daily for 4 days preceding and 20 days 
after, the virulent inoculation. Besides these, 3 healthy animals were 
used from time to time for comparison, and agglutination tests were 
also made each day. 

In this series about i c.c. of blood was drawn each day from the ear vein 
and the serum used within two hours. 

Instead of incubating the specimens in the measuring pipettes as de- 
scribed by Wright we found it more convenient and the results better by em- 
ploying miniature tubes into which the mixture was transferred after meas- 
uring. These " mixers " were placed in holes of a wooden block during incu- 
bation like cribbage counters. 

No marked difference was noted between vaccinated and control 
serums before and immediately after the virulent inoculation. Both 
sets showed considerable individual variation from day to day, but all 
were weaker on the first two days following infection. The vaccinated 
serums were usually below the controls in opsonic power from the 
beginning, and 2 pairs which had shown the greatest variation, when 
bled to death, revealed the typical differences elsewhere described 
between the lungs of the vaccinated and controls to a marked degree. 
One pair was killed on the i6th day, the other on the 20th day. Both 
vaccinated serums sedimented Koch's emulsion 1-40 and 1-20, respect- 
ively; the controls were negative. 

If the intense reactive infiltration is regarded as an active phago- 
cytosis, which it appears to be in part, the lower opsonic power of 
the serums may be accounted for by its exhaustion though evolved 
in excess of that in the controls. On the other hand the higher opsonic 
value of the control serum, and the excess of the agglutinin simul- 
taneously with lower opsonin in the vaccinated are phenomena that 
need explanation. 

No coincidence was noted in our experiments between the agglu- 
tination of Koch's emulsion and opsonic power, although the phago- 
cytosis was generally more complete when the serum agglutinated the 



148 NAT. ASS'n for study AND PREV. OF TUBERCULOSIS 

bacilli. Studies on the relation between the agglutinins and opsonic 
power are in progress. 

As a final observation we may state that the intense reaction seen 
in vaccinated rabbits was observed only in the lungs, where doubtless 
most of the bacilli lodge; and in a few animals the reaction was evi- 
dently followed by such lowered resistance that instead of absorption, 
large caseous areas developed much more extensively than in the con- 
trols. Thus one cannot say that the method of vaccination always 
succeeds at last in destroying the bacilli and removing the tubercles, 
though it must be remembered that these inoculations are extremely 
severe conditions for animals to withstand. Moreover, the absorption 
of foci in the controls was occasionally observed to nearly the same 
degree, and the presumption is that the mechanism is the same but 
delayed and less active in unvaccinated animals. 



STUDIES ON IMMUNITY IN TUBERCULOSIS 

Part II 

AN HISTOLOGICAL STUDY OF THE LESIONS OF 
IMMUNIZED RABBITS 

By Joseph L. Nichols, M. D. 
Saranac Lake, N. Y. 



The following examination was conducted for the purpose of 
demonstrating the histological differences in the formation and further 
progress of tubercles in previously vaccinated and in unvaccinated 
animals already described in Part I. 

In former experiments by Dr. Trudeau the great value of previous 
vaccination was shown by the survival, or greatly prolonged lifetime, 
of the vaccinated animals, and by the death of nearly all the unvacci- 
nated. In those experiments a number. of animals in each series were 
killed on the twenty-second day after the virulent inoculation, and mi- 
croscopic examination made by Dr. Eugene Hodenpyl^ showed a 
marked difference between the lungs of the vaccinated animals and 
those of the controls. The former were densely infiltrated and more 
congested than the controls, while vaccinated animals killed some 

* Transactions of Association of American Physicians, Vol. XVIII, 1903. 

Sections from some of these rabbits were made and examined by Dr. 

Hodenpyl with the following results, which agree substantially with my own : 

A. Vaccinated rabbits ; no virulent inoculation ; killed after 80 days : No 
trace of inoculation. 

B. Control ; killed 22 days after virulent inoculation : Many t. be. ; little 
general reaction. 

C. Vaccinated ; killed 22 days after virulent inoculation : Greater reac- 
tion ; air cells full of exudate and epithelioid cells ; less definite arrangement 
as tubercles ; some caseation ; numbers of t. be. 

Di, Dj. Vaccinated; killed no days after virulent inoculation (controls 
had all died tuberculous) : A few very minute scattered tubercles composed of 
few epithelioid cells and a single layered capsule ; a few larger tubercles with 
caseated centers ; no t. be. ; rest of lung tissue apparently completely restored 
to normal. 

149 



150 NATIONAL ASSOCIATION FOR THE STUDY 

months later revealed a remarkable absence of tuberculous foci and 
bacilli in the lungs, thus indicating an extensive absorption of the in- 
filtration. 

In order to try to follow the successive stages of this reaction the 
present experiment was conducted on the same lines, with the differ- 
ence that one of each set of animals, i, e., vaccinated and unvaccinated, 
was killed at certain intervals after the virulent inoculation, varying 
from twenty-four hours to thirty days. The blood serum was tested 
for agglutinins by Dr. Baldwin, while the internal organs were given 
to me for microscopical examination. 

The two sets of animals reacted differently to the virulent inoc- 
ulation, the vaccinated showing for the first three or four days a 
distinctly higher temperature and greater general disorder. In the en- 
suing week, however, the condition was gradually reversed; the vacci- 
nated animals returning to a normal appearance without having lost 
flesh, while the unvaccinated began to decline. 

This difference in reaction of the two sets of animals was still 
more marked on examination of the internal organs. For this purpose 
one of each set, selecting animals as nearly alike as possible, was killed 
every twenty-four hours for the first three days; then on the fifth 
and eighth days ; and thereafter up to the thirtieth day at intervals of 
about four days. The animals were killed by bleeding and the autopsy 
performed at once. Small selected pieces were taken from the lungs, 
liver, spleen, and kidneys, hardened in Orth's fluid, embedded in cel- 
loidin, and the sections stained ; some in hsematoxytin and eosin, others 
by the Ziehl-Neilsen method for tubercle bacilli. 

Attention may be drawn to the fact that because these animals 
were killed at regular progressive intervals, it does not necessarily 
follow that the lesions will be found in exactly the same proportionate 
advance. We must allow for differences in the individual resistance, 
and some variation in the dose no matter how carefully given. How- 
ever, the periods between each killing have been sufficiently long to 
allow some definite advance over the preceding ones in each succeeding 
set. 

The following description will be confined to the lungs. I shall 
take up first a description of the general reaction in each case, and 
discuss afterwards any difference in the specific elements of tubercle 
formation. 

Already, at the end of twenty-four hours, there is a difference 



AND PREVENTION OF TUBERCULOSIS I5I 

between the lungs of the vaccinated and control, evident to the naked 
eye. The latter appear unchanged. The former are congested, and 
somewhat denser than normal, and scattered through the tissues, or 
just beneath the pleura, are small punctate hemorrhagic spots. On 
distention of the lung with fluid these spots for the most part disappear. 

Under the microscope we find in both sets of animals the bacilli 
of the virulent inoculation pretty evenly scattered through the section 
as small clumps in the capillaries forming a thrombus composed of 
bacilli, fibrin, and many leucocytes. In the control the reaction has 
extended little further than this. In the vaccinated animal, however, 
the way seems to have been prepared for an immediate and powerful 
reaction. All capillaries throughout the section are greatly congested, 
and contain many leucocytes. About the foci of bacilli the congestion 
is very intense, and at some points small haemorrhages have occurred. 
There is already some exudate containing a number of " epithelioid " 
cells; i. e., cells with large, clear vesicular nuclei; and similar cells 
may be seen in the alveoli adjoining the tubercle. These latter are 
probably in part desquamated epithelium. 

In the vaccinated animals during the next two days, the number 
of these characteristically formed tubercles has materially increased, 
as well as their size. The " epithelioid " cells in the center of the 
tubercle contain numbers of tubercle bacilli. Occasionally these cells 
containing tubercle bacilli are seen in a neighboring alveolus, or 
capillary. The bacilli are thus more or less scattered, and are beginning 
to lose their brilliant stain and regular contour. There is also some 
evidence of nuclear fragmentation, and a clearer zone in the center of 
the tubercle, but no sign of necrosis. 

In many places the newly formed cells have either coalesced, or. 
their protoplasm has not divided, and we find giant cells made up of 
a large mass of protoplasm containing several* more or less centrally 
placed, large, vesicular nuclei, and sometimes a number of tubercle 
bacilli. 

At the end of the fifth day we find the lungs of the vaccinated 
animal very voluminous (not collapsible),- very much congested, and 
speckled with large and small haemorrhagic spots, one or two as large 
as a pea. Numbers of minute, translucent tubercles can be plainly seen 
with the naked eye. Under the microscope these differ from an ordi- 
nary tubercle of the same size in the unusual amount of exudate and 
epithelioid cells ; in the apparent degeneration of the bacilli in the center 



152 NATIONAL ASSOCIATION FOR THE STUDY 

of each ; and in the spread of exudate and number of " epithelioid " 
cells to the intervening septa and alveoli. The margins of these tu- 
bercles are intensely injected with blood, which in many places has 
escaped from the capillaries. 

Where several tubercles are adjacent this congestion and extra- 
vasation cover quite a large area, and become visible to the naked eye 
as the haemorrhagic spots already spoken of. 

So far, the controls have remained much the same as on the first 
day. The control of this date, — the fifth day, — shows only slightly 
greater congestion and density of the lungs than normal. There are 
no tubercles visible to the naked eye. Under the microscope numerous 
small tubercles can be made out, varying greatly from the vaccinated, 
in that they are much smaller, contain little exudate, almost no cells 
of the epithelioid type, and many brightly staining tubercle bacilli, 
showing no signs of degeneration or inclusion in phagocytes. There 
is little or no reaction in the intervening septa. 

It was thought the haemorrhagic spots spoken of might be due 
to the remains of the previous vaccination, as they were noticed only 
in the vaccinated animals, and were so pronounced and constantly 
present. Therefore an extra vaccinated animal, which had received no 
virulent inoculation, was injected with 50 mg. tuberculin, at the same 
time as an unvaccinated animal which had received a test intravenous 
inoculation of the virulent culture three weeks previously. Both were 
killed on the following day. The former showed no reaction to the 
tuberculin ; the latter a slight one. On section the lungs of the vacci- 
nated showed no haemorrhagic spots, and under the microscope no 
trace of the original vaccination could be found except one or two very 
minute clumps of newly formed connective tissue cells, enclosing a 
couple of old, degenerate-looking tubercle bacilli, all that had remained 
of the vaccination at the end of sixty-eight days. The lungs of the 
second animal contained easily visible tubercles, well circumscribed, 
and with beginning caseation and numerous tubercle bacilli in the cen- 
ter, and a zone of hypercongestion about the periphery, perhaps due 
to the tuberculin. The haemorrhagic spots, therefore, are evidently a 
part of the intense reaction produced in the vaccinated animals by the 
injection of the virulent organism, and not due to any remains of the 
original vaccination. 

The ensuing six pairs of animals were killed at intervals of about 
four days, and are especially interesting, as this period, — from the 



AND PREVENTION OF TUBERCULOSIS 1 53 

fifth to the thirtieth day, — seemed to complete the mastery of the 
infection by the vaccinated animals and to usher in the final stage to 
complete absorption of all these inflammatory products, while in the 
unvaccinated animals the infection progresses gradually to the for- 
mation of chronic tuberculous lesions. 

If we examine the lungs of the first of these vaccinated animals 
killed nine days after the virulent inoculation, we are struck by their 
great alteration, and would be inclined to conclude that the animal 
was under the influence of a very severe infection. The lungs are 
very dense and voluminous, do not collapse, are mottled, dusky pink 
in color, with here and there very dark red haemorrhagfic spots. The 
surface is very irregular, where numerous, sometimes coalescing tu- 
berculous nodules protrude. On carefully examining these they are 
seen to be of a somewhat more translucent, opalescent appearance than 
in the control. The lungs of the control of this date present very little 
alteration to the naked eye. They collapse a good deal, and are only 
slightly more congested than normal lungs. On careful examination 
minute, dense, gray-looking tuberculous nodules, scarcely perceptible 
to the touch, are visible to the naked eye, scattered through the lung 
tissue. On examining the lungs of the vaccinated animals under the 
microscope we find the large, opalescent, irregular nodules to be com- 
posed of several small, well defined tubercles bound together by a mass 
of exudate, epithelioid and desquamated cells, which fill up the ad- 
joining alveoli and septa, the whole surrounded and permeated by 
extravasated blood, and highly congested capillaries, which are also 
packed with leucocytes. The whole has more the appearance of a 
pneumonia than the gradual newly forming connective tissue of an 
ordinary tuberculous process of the same extent. The individual tu- 
bercles are filled with large epithelioid cells, with pale vesicular nuclei, 
with some polymorphonuclears, loosely held together by a plentiful 
homogenous exudate. In the center of these is some nuclear fragmen- 
tation, but no appearance of beginning caseation. In this portion only 
are tubercle bacilli to be found, and there are very few indeed, and 
nearly all fragmented and degenerate-looking. All through these small 
nodules of exudate, cells and minute tubercles, are seen many karyo- 
kinetic figures, and giant cells of the type spoken of above ; evidences 
of great cell activity. All sizes and shapes of nuclei are to be seen. 
The tubercles in the control of this date are much like the previous 
one, and consist mainly of conglomerate small areas of leucocytic in- 



154 NATIONAL ASSOCIATION FOR THE STUDY 

filtration, containing little exudate, and few epithelioid cells, but many 
brightly staining, clearly defined bacilli. 

The next two succeeding vaccinated animals, killed on the twelfth 
and seventeenth days, resemble very closely the preceding one. There 
is, however, a marked diminution in the number of tubercle bacilli, 
and in the latter one they are exceedingly hard to find. On the twenty- 
second day the gross appearance has little changed, but on microscopic 
examination we find a slight clearing up of the cellular exudate in the 
intermediate tissue and that the tubercle bacilli have apparently disap- 
peared. The small tubercles are often sharply circumscribed by a single 
layer of epithelioid cells, and there is, as before, much extravasation of 
blood within and surrounding them. All these last three animals 
showed a good deal of cellular detritus in the smaller bronchioles, and 
occasionally tubercle bacilli could be seen within some of these cells. 

In the remaining two vaccinated animals a remarkable change has 
taken place in the absorption of the cellular exudate from the septa and 
alveoli lying between the small tubercles, so that this portion of the 
lung has nearly returned to its normal appearance. The tubercles 
themselves seem to be breaking up, the central portion dissolving out, 
while the peripheral capillary ring is reduced to slightly congested 
vessels, and a number of darkly staining leucocytes. Many of these 
tubercles have been reduced to nothing more than a few large, pale 
vesicular cells, surrounded by a small capillary ring whose limits are 
somewhat emphasized by a greater number of nuclei than normal. 

As to the controls, it will be remembered that those up to the 
seventeenth day showed no very marked reaction. At this date, how- 
ever, there is a marked advance. The tuberculous nodules are much 
more fully developed. In gross appearance they are denser gray look- 
ing than in the vaccinated ; they are smaller and more sharply marked 
off from the surrounding tissue. Under the microscope these nodulfes 
are composed, like the vaccinated, of several small tubercles joined 
together by a cell infiltration. Their character, however, differs some- 
what. There is less exudate, fewer epithelioid cells, more deeper 
staining leucocytes, and more cells resembling new connective tissue 
corpuscles. These last are especially marked in the intervening sub- 
stance, which thus has a firmer, less succulent appearance. There is 
also some karyokinesis. What is of more importance, there are, in the 
central portion of the individual tubercles, considerable fragmentation 
and necrosis, and numerous brightly staining tubercle bacilli. Few of 



AND PREVENTION OF TUBERCULOSIS 1 55 

these are within cells. In the next succeeding control, killed twenty- 
five days after inoculation, there is more fragmentation in this portion, 
with beginning caseation and many bacilli. In the intervening tissue 
are found numerous fibrous tissue corpuscles, and many giant cells of 
the small darkly staining eccentric nuclei type generally seen in be- 
ginning fibrous tuberculous tissue. In the last control a similar con- 
dition exists, though some of the tissue in between these conglomerate 
tubercles has cleared up, and rarely we may find a small tubercle 
undergoing resolution. The bacilli are still present in large numbers. It 
is to be regretted that more animals were not used in this experiment so 
that the virulent infection could have been followed in its further stages.^ 

As an ultimate result, then, at the end of thirty days, the lungs of 
the vaccinated are practically free from tubercle bacilli, and nearly 
cleared of all signs of their invasion ; in the control, on the other hand, 
the great majority of the tubercles are still progressing, undergoing 
fragmentation and caseation, and containing many tubercle bacilli in 
their centres, while their periphery and intervening substance are 
apparently undergoing a change into more durable fibrous tissue. 

Of the elements more or less specific of tubercle formation, I will 
consider before closing the giant cells, the " epithelioid " cells, and 
lastly the tubercle bacilli. 

From the foregoing it will already have been noticed that g^ant 
cells of the type represented by a mass of protoplasm containing two or 
more nuclei, more or less centrally placed, appear in the vaccinated as 
early as the third day and continue until the twenty-fifth, reaching their 
maximum in the seventeenth day, when also some giant cells of more 
eccentric type accompany them, and a good deal of evidence of cell 
division. In the controls, on the other hand, giant cells do not make 
their appearance until the twenty-fifth day, and are then nearly all of 
the type with eccentric dark staining nuclei seen in fibrous tuberculous 
tissue. It seems probable that the presence and numbers of giant cells 
of the vesicular nuclei type, like the nuclei of the " epithelioid " cells, 
have some dependence on the rapid appearance of large numbers of 
these cells at the foci of disease in the vaccinated animals. 

These epithelioid cells, which appear in the earliest specimens of 
the vaccinated animals have a good deal of protoplasm, and large vesic- 

^ The study of the stages up to the 6ist day was made later on the second 
series (see Part I), and in some animals absorption was still in progress on the 
50th day. Otherwise nothing new was developed. 



156 NAT. ASS'n for study AND PREV. OF TUBERCULOSIS 

ular nuclei. It seems hardly likely that they are produced so quickly 
and in such large numbers from local elements. It is more likely that 
they come with the excessive exudate from the blood, the capillaries 
being from the first surcharged with blood, containing vast numbers of 
leucocytes. These " epithelioid " cells possess great phagocytic power. 
From as early as the second day, many may be seen containing four or 
more tubercle bacilli, mostly in the tubercles, sometimes in an adjacent 
capillary or alveolus, and later in the smaller bronchioles. This is also 
true of the giant cells of this type. 

The tubercle bacilli show early signs of degeneration in the vacci- 
nated animals, and rapidly diminish between the fifth and ninth days, 
to disappear almost entirely by the thirtieth day. In a few sections, 
however, of the vaccinated animals, in spite of the care with which the 
emulsion was made, a very large clump of tubercle bacilli had lodged, 
making a more resistant focus, and out of all comparison with the 
surrounding process. These can be disregarded. 

In the controls, on the other hand, although some tubercle bacilli 
are undoubtedly taken up and destroyed, they are still present in all the 
specimens in considerable numbers, and in the thirtieth day may be 
found, apparently little diminished in numbers and virulence, about the 
fragmentation and caseation which has begun to make its appearance. 

In conclusion, then, it may be said about this manner of vaccina- 
tion, that, within a given time at least, it prepared the way for an 
immediate and powerful reaction. Apart from the speed and intensity 
with which it develops, and the proportionate excess of exudate, and 
of epithelioid elements, this tubercle does not differ in cellular character 
from the tubercle of the control. It does differ, however, in its ultimate 
result in that it effects the death of the tubercle bacilli within it. and 
ends by being completely absorbed. It does not go on to caseation nor 
the formation of chronic tuberculous tissue. The reason for this must 
be sought in an increased bactericidal power of the exudate ; in the in- 
creased capacity or numbers of the phagocytes, the " epithelioid " cells, 
or, as recent work has shown, a combination of both these elements. 

In these sections it was very difficult to determine the exact bound- 
aries of the cells, and whether the bacilli were actually within or with- 
out them, so that a definite difference in phagocytosis between the vac- 
cinated and controls was difficult to determine. Certainly there were 
much earlier definite evidences of it in the vaccinated, and it was easier 
to find cells that evidently contained bacilli in those specimens. 



TWO EXPERIMENTS IN ARTIFICIAL IMMUNITY 
AGAINST TUBERCULOSIS 

By E. L. Trudeau, M. D. 
Saranac Lake, N. Y. 

(Presented as part of the Discussion on the preceding papers) 



Gentlemen : As the papers which have just been read relate to 
the difference of the pathological lesions produced in animals immu- 
nized against tuberculosis by attenuated living cultures, also to the value 
of agglutination in the various degrees of tuberculous infection and to 
the opsonic power of the blood of immunized and compared with unim- 
munized animals, I am glad to avail myself of the privilege accorded 
me by your Chairman of describing to you two experiments recently 
made by me which bear on artificial immunity against tuberculosis 
in small animals. 

Many of you who have followed carefully the continued but 
apparently hopeless efforts to produce artificial immunity against this 
disease, in which clinically no acquired immunity seems to exist, and 
where one attack apparently does not protect from another, and who 
remember the many failures which have followed attempts at producing 
an antitoxic serum for tuberculosis or immunity against the disease by 
tuberculin or other products of the germ, may nevertheless have been 
struck with the fact that rather better results have been claimed at 
mtervals during the past thirteen years by a certain class of experi- 
menters. 

I refer principally to the work done by de Schweinitz, Pearson and 
GilHland, and Trudeau, in this country, that of MacFadyean in 
England, and Behring, Neufeld, Baumgarten, and also Moeller and 
Friedmann, in Germany. The distinctive feature of their work is 
that the immunity claimed, whatever its degree, is produced not by a 
toxin but by a preventive inoculation made with living but attenuated 
bacilli. These bacilli may depend for their attenuation either on the 

157 



158 NATIONAL ASSOCIATION FOR THE STUDY 

selection of a race of tubercle bacilli not naturally virulent for the 
animals to be protected, or on prolonged cultivation on artificial media 
which produces attenuation of virulence in the same variety of tubercle 
bacillus naturally virulent for the animal sought to be protected. 

Marmorek and Maragliano still claim to produce antitoxic and 
bacteriolytic serums which are effectual when employed in the treat- 
ment of human tuberculosis, but sufficient time has not elapsed to 
establish the validity of their claims. In my own work the best results 
I have obtained in producing a relative but demonstrable degree of 
immunity, or at least increased resistance in small animals, have been 
brought about by the previous inoculations of living but attenuated 
cultures, and have been published at long intervals since 1893. 

Rabbits and guinea-pigs, which I have always made use of, are by 
no means ideal animals for immunization, the guinea-pig being almost 
too susceptible, so that nothing more than relative immunity can be 
obtained with these animals; the rabbit, on the other hand, recovering 
very readily after a time from even intravenous inoculations of human 
tubercle bacilli, unless these be very virulent or the amount injected 
very large, so that the control animals have a disagreeable way of 
making relative if not complete recoveries. 

It having been demonstrated by de Schweinitz and by myself 
that a human culture by prolonged cultivation lost its virulence for 
even such susceptible animals as guinea-pigs, and that its injection gave 
these animals a relative degree of immunity, I began over a year ago 
experiments to try to throw more light on the nature of this very 
apparent protection. 

The first experiment I made was with a view to determining 
whether a living bacillus was necessary to the production of the highest 
degree of immunity attainable, or whether dead bacilli would be equally 
effective. Was the immunity a result of the struggle between the living 
bacillus and the germ, or was it merely the chemical products of the 
germ which were essential to success, living or dead? Was the 
immunity simply a toxin immunity, or was it a bacteriolytic or isopathic 
immunity which could be induced only by the substance resulting from 
the struggle between the living cells and the living but attenuated 
germs ? The conditions of the experiment were as follows : 

Guinea - pigs of the same weight were chosen. Twelve were 
injected in the left groin with one-half milligram attenuated, actively 
growing, human culture (R i). The culture was then put in the steam 



AND PREVENTION OF TUBERCULOSIS 1 59 

Sterilizer for fifteen minutes, and twelve more guinea-pigs were 
similarly inoculated. In a month they received one milligram of the 
same attenuated culture (living and dead) intraperitoneally. A month 
after the first vaccination the pigs injected with the living bacilli 
showed slight enlargement of inguinal glands, but nothing more. 
Those injected with the dead bacilli showed no evidence whatever of 
the inoculation. A month after the last protective inoculation they 
were all injected in the right groin, along with eight control animals 
of the same size, with one milligram virulent human tubercle bacilli. 
The last of the controls died in ninety days with gross and advanced 
cheesy lesions in glands, spleen, liver and lungs. At that time (ninety 
days) four of the pigs vaccinated with dead tubercle bacilli had died, 
and none of those vaccinated with living. One of the animals from 
each of the two lots of vaccinated pigs was then killed in order to 
compare their lesions with those of the controls. As you see in the 
reproductions I show you, the lesions of the controls and those of the 
animals vaccinated with dead tubercle bacilli differ but little. They 
both have cheesy nodes, enormous cheesy spleens and livers, and the 
lungs are extensively invaded with cheesy tubercle. The difference 
in the gross appearance of the organs of the animal vaccinated with the 
living culture is, however, apparent at a glance; namely, though the 
nodes are enlarged, and the spleen moderately so, there is as yet no 
evidence of caseation recognizable to the naked eye. In other words, 
the animal is tuberculous, and would, like the rest of those in the same 
lot, have died ultimately of tuberculosis as they all do, but the living 
vaccination had a ver>- decided and easily demonstrable influence in 
arresting the progress of the disease ; an influence which proved to be 
undemonstrable in the animal vaccinated with the same culture 
previously killed by heat, but which nevertheless is found to be present, 
though to a less degree, when the duration of Hfe in a larger number of 
animals is considered. 

The test inoculation in this particular lot of animals was more 
virulent and much larger than is best to use in order to demonstrate 
the immunity conferred by the vaccination, but that some slight pro- 
tection is afforded even by the dead bacilli, under so severe a test, is 
apparent when the duration of all the animals' lives is considered. Thus 
the controls' average life was 70^ days ; the average life of the animals 
vaccinated with dead bacilli 99 days; and with living bacilli 155 days. 
It would seem that a very marked protection is afforded by the living 



l6o NATIONAL ASSOCIATION FOR THE STUDY 

bacilli, and a very slight but still appreciable degree o£ increased re- 
sistance by the dead bacilli. Such evidence is important in its bearing 
on the treatment of tuberculosis by Bacillen Emulsion, some observers 
still maintaining that good results are obtainable from this treatment 
in the human being, though no very marked immunity is produced. 

This experiment is no doubt open to the criticism that in killing the 
cultures by heat their chemical constituents may have been altered, and 
that if they could be killed by some method that would not in any 
way change their delicate chemical composition the dead bacilli would 
protect as well as the living. To obtain some evidence on this point 
another experiment was undertaken. Small amounts, one-tenth milli- 
gram, of dead bacilli killed by three hours' exposure to sunlight were 
injected at short intervals in pulverized form, and the protection 
afforded was less marked than where the heat-killed cultures were 
employed. 

Average life for nine controls, 87.4 days. 

Average life for twelve vaccinated, 95 days. 

The next experiment, also gives some evidence rather tending to 
disprove this hypothesis. 

During the past year Moeller, and later, Friedmann, have used 
bacilli derived from or passed through cold-blooded animals as a pro- 
tective inoculation, and have claimed marked results from these vacci- 
nations in guinea-pigs and rabbits ; much better results, it seems to me, 
than I was able to obtain with my attenuated tubercle bacilli of human 
origin. Moeller used a tubercle bacillus culture which was derived 
from the frog, and one which had been passed through the slowworm. 
Both these cultures grew freely on glycerine peptone agar at room 
temperature, and Moeller claimed that as they would not grow at the 
temperature of the human bady they were perfectly safe to use as a 
vaccine, an advantage which could not be said to be possessed by the 
bacillus of human origin and growing at the temperature of warm- 
blooded animals only, no matter how attenuated it might have become 
by prolonged cultivation on artificial media in the thermostat. 

These two varieties of cultures, the frog and the slowworm, Dr. 
Baldwin was enabled to obtain from Dr Moeller, and they were grown 
in our laboratory at room temperature. I determined to make an ex- 
periment that would be likely to shed light, — 

First, on the degree of protection afforded by cultures of warm- 
blooded origin but attenuated by prolonged growth, as compared with 



AND PREVENTION OF TUBERCULOSIS l6l 

that conferred by bacilli derived from cold-blooded creatures and which 
apparently die at once when introduced into warm-blooded animals. 

Second, to determine whether the degree of attenuation obtained 
by prolonged growth bears any relation to the degree of protection 
afforded; that is, whether a culture of human origin grown for over 
twenty years on artificial media, which produces now little or no appre- 
ciable local lesion and never tends to generalize itself, will protect as 
well as one also of human origin which has been cultivated for over 
fourteen years, and which still produces in all the guinea-pigs slightly 
enlarged inguinal nodes near the site of inoculation, and occasionally 
even — that is, in about one in ten animals — brings about a Httle 
caseation in such a node, with a tendency to become generalized to the 
extent that bacilli in a few instances reach as far as the spleen. 

The former culture is designated K i, and is one of the original 
cultures which Dr. Koch separated in his first work on tuberculosis. 
The second is my old R i culture, which I obtained from the human 
subject, and has grown, principally on glycerine peptone bouillon, about 
fifteen years. 

On February 27th, 1905, 48 guinea-pigs of the same size were 
separated into four groups, and each group received respectively, in 
the left groin, one-half a milligram of each of the following vigorously 
growing agar cultures : Lot I, human R i culture ; Lot II, human K i 
culture; Lot III, cold-blooded (frog), and Lot IV, cold-blooded (slow- 
worm) culture. A month later one of each group was killed. Slow- 
worm and frog guinea-pigs showed absolutely no lesion. K i animals 
showed enlarged nodes, no caseation or tubercle bacilli. R i, one or 
two enlarged nodes, slight caseation and a few tubercle bacilli. No 
other lesions anywhere. The animals were all tested with tuberculin, 
and only the Lot I, human culture R i, pigs gave any reaction. 

March 27th. 33 days after vaccination all the vaccinated animals, 
together with twelve controls, were injected subcutaneously in the right 
groin with one-tenth milligram virulent human tubercle bacilli culture. 
All the 55 animals were killed at the same time, May loth, or 44 days 
after the virulent inoculation, and having been divided in five lots were 
laid out side by side for comparison. The animals of each lot were 
quite uniform in the character and extent of their lesions. 

Lot I, Vaccinated zvith R i Huvian, show enlarged and occasion- 
ally cheesy nodes, slightly enlarged spleen, abundant perirenal fat. No 
other macroscopical lesions are visible, no tubercles or caseation. 



r62 NATIONAL ASSOCIATION FOR THE STUDY 

Lot II, Vaccinated with K i Human, show caseous nodes and 
much larger spleen (over twice as large as Lot I) ; absence of perirenal 
fat marked in nearly half the animals, but no caseous tubercles, though 
a few gray tubercles could be seen in liver and lung in about one-third 
of the animals. 

Lots III and IV, Vaccinated with cultures from cold-blooded 
animals (frog and slowworm), as well as the controls, all show to about 
the same degree the usual picture of well advanced generalized tubercu- 
losis in the guinea-pig. Spleens about three times the size of Lot II, 
riddled with gray caseating tubercle. Entire absence of perirenal and 
lumbar fat, cheesy areas in liver, and gray tubercle in the lungs. 

The controls and animals of Lots III and IV were in no way 
distinguishable, while any one of the animals. Lot I and Lot II, could 
have been picked out easily if thrown among controls, or animals vacci- 
nated with cultures frorh cold-blooded animals. 

This experiment seems to offer some interesting evidence. First, 
there is evidently a relation between the degree of protection and the 
attenuation of the culture used as a vaccine. The R i human, which 
from its production of local effects, enlargement of neighboring nodes 
containing bacilli, and slight tendency to generalization (bacilli having 
been found occasionally in the spleens of animals injected with this 
attenuated culture), protects better against subsequent virulent inocu- 
lation than the K i culture, which produced hardly any appreciable 
and purely localized effect, no bacilli being found to have penetrated 
even the inguinal glands near the inoculation spot. 

The frog and slowworm bacillus, which causes no local disturbance 
at all, seemed to have no effect in protecting the vaccinated animals, 
for the lesions of these exactly resembled those of the controls. The 
conclusions to be drawn from both of these experiments would there- 
fore seem to be, — 

First, that dead tubercle bacilli increase, though to a very slight 
degree, the animal's resistance to subsequent inoculation. 

Second, that the living attenuated bacillus gives a stronger degree 
of immunity than the same bacillus killed by heat. 

Third, that the degree of attenuation of the bacillus used as vaccine 
bears a distinct relation to the degree of protection it affords in guinea- 
pigs to subsequent inoculation with virulent human cultures. That a 
culture still capable of producing a very small amount of cell destruc- 
tion, and of spreading to the neighboring inguinal nodes, gives better 



AND PREVENTION OF TUBERCULOSIS 163 

protection than one which produces hardly any appreciable and purely 
localized tissue changes. 

Fourth, that cultures derived from cold-blooded animals and 
which only grow at room temperature, as used above, have brought 
about no appreciable degree of immunity. 

Fifth, the chemical changes produced in killing the bacilli by heat 
in the first experiment cannot wholly explain the lack of protective 
power of the vaccination with dead bacilli, for the K i human bacilli 
used in the second experiment, though they had not been killed by heat, 
failed to give as good protection as the R i human culture, which dif- 
fered from it only in the degree of its virulence. 

The evidence here presented would seem to be in keeping with 
what we know of the artificial immunizations. Toxin immunity, or 
immunity brought about with dead germs, is never as strong or as 
. lasting as that produced through the medium of a living virus (passive 
and active immunity). Furthermore, the degree of the attenuation of 
the virus greatly influences the degree of immunity obtained. 

My acknowledgments are due to Dr. E. R. Baldwin, Dr. Hugh M. 
Kinghorn, and Dr. A. H. Allen, who carried out these experiments 
for me. 

DISCUSSION ON THE PAPERS OF DRS. WELCH, RICHER, KING- 
HORN, RAVENEL, LANDIS, BALDWIN, ALLEN, NICHOLS AND 
TRUDEAU 

Dr. William H. Welch, Baltimore: The Section is to be con- 
gratulated upon the presentation of such a very important series of 
investigations. It is satisfactory to know that these studies were 
initiated by Dr. Trudeau and have been carried on so successfully by 
him and through him. I would like to inquire whether Dr. Trudeau 
found that the establishment of agglutination is really a valuable index 
as to the method of demonstating the action of tuberculin as a guide 
to prognosis. Dr. Wright has opened up a valuable field of investi- 
gation, as he thinks he has a method of determining predisposition to 
tuberculosis. I would like to know what Dr. Baldwin thinks of this. 
The observations of Dr. Nichols are interesting from a biological point 
of view. It will be noted that the vaccinated rabbits might be said to 
be more susceptible to the tubercle bacillus, but there is some question 
when that animal is protected far beyond the control animal. These 



1 64 NATIONAL ASSOCIATION FOR THE STUDY 

experiments are of extraordinary interest as regards the interpreta- 
tion of the results obtained. 

Dr. Leonard Pearson, Philadelphia: It is a treat to hear such 
good reports this morning. As Americans, we should dwell upon the 
point that the first work in the world was done by Dr. Trudeau. In 
Germany an active discussion is going on as to whom belongs the 
credit for the application of immunity against tuberculosis, Koch or 
von Behring, but the work of Trudeau and DeSchweinitz antedates 
either one. I have looked into Trudeau's work in using tubercle ba- 
cillus from cold-blooded animals, and was very little impressed by it. 
The cold-blooded organism is now very rarely used. The Berlin 
workers have shown that the tubercle bacillus has not really been used 
for some time. The burning question is the application of immunity 
to man. It is not likely that any one will submit himself to inoculation 
with human bacilli in order to get immunity. It seems to me that we 
cannot gain minute information as to the tubercle bacillus except by 
inoculating an animal with the same kind of bacillus. I have carried 
on some experiments in the vaccination of monkeys. They have been 
exposed by contact and we have not found any perceptible degree of 
immunity. The degree of immunity obtained by vaccination is not ab- 
solute. It should be graduated, however, by the amount and method. 
The more the vaccination within certain limits the greater the im- 
munity. I imagine it will always be possible to infect an animal with 
tuberculosis if the amount used be large enough. So far as vaccinat- 
ing cattle against tuberculosis is concerned, we may safely say that 
we have reached that point. 

Dr. Wm. H. Welch, Baltimore: Klemperer has injected mice 
subcutaneously with bacilli, but found no results. Miiller has also made 
some remarkable experiments on mice. 

Dr. Edward L. Trudeau, Saranac Lake: As to whether tuber- 
culin injections increase agglutination I have had no personal expe- 
rience. Neither of my experiments were made with Friedmann's ba- 
cillus, r was under the impression that the cow gets its immunity by 
vaccination with human bacilli and not by attenuated bovine bacilli. 
I do not claim that the prolonged growth of the bacilli is necessary. 

Dr. Leonard Pearson, Philadelphia: The human organism in- 
oculated into cattle does tend to immunize against bovine tuberculosis, 
Cut it seems to be valueless for the other species. 

Dr. E. R. Baldwin, Saranac Lake: We are trying to copy Dr. 



AND PREVENTION OF TUBERCULOSIS l6$ 

Wright's technique. Personal equation enters very largely into the 
counting of the bacilli. We have acquired considerable skill in this 
direction and two or three of us agree fairly closely in our counts. 
Unless the technique is very much simplified, it cannot be of very 
great practical value. We have not worked it out on the human blood. 
The general impression is that the agglutination test by means of the 
living homogeneous bacillus is quite useless as a diagnostic means. 
Careful study of the figures will show that the claims are true as to 
the value of the agglutination test. We may see in these cases that 
these perfectly healthy people do not have a slight focus even when 
they were in very close contact with tuberculous patients. 



EXAMINATION OF THE BLOOD IN PULMONARY 
TUBERCULOSIS, WITH SPECIAL REFERENCE 
TO PROGNOSIS 

By Josephus T. Ullom, M. D., and Frank A. Craig, M. D. 

Philadelphia 

(From the Laboratory of the Henry Phipps Institute) 



Historical. — The blood in tuberculosis has for many years been 
the subject of investigation by many different observers. Among the 
first series of clinical examinations of the blood we find cases of tuber- 
culosis recorded; as these earlier reports were based upon methods of 
examination so different from those now in use and the details of the 
condition of the patient are so commonly omitted, they are of very little 
service for comparison with the more recent examinations. 

In tuberculosis we have such a chronic condition, one which 
presents so many different phases, types and complications, and which 
may affect so many organs, that it is not to be wondered at that the 
results of blood examinations by different observers vary so widely. 
It is, therefore, only by taking the statistics, classifying the findings 
in different types of tuberculosis, and studying them in relation to one 
another that we can hope to derive any information of value for di- 
agnosis and prognosis. 

HEMOGLOBIN. — As this was the first component of the blood to 
be studied quantitatively for clinical purpose we find a large series of 
estimations of this element. The methods varied greatly from the 
spectroscopic to the purely chemical, which renders the results hard to 
correlate. That the haemoglobin is constantly reduced in bone tuber- 
culosis has been shown by Vierordt, Lacker, Bierfreund, and Dane. 
That, on the other hand, this reduction is not constant in pulmonary 
tuberculosis of various grades is shown by Leichtenstern, Gnezda, 
Barbacci, and Oppenheimer, who found fairly numerous cases in which 

i66 



NAT. ASS'n for study AND PREV. OF TUBERCULOSIS 1 67 

the haemoglobin was above normal. Quinquaud, Wiskeman, Laache, 
Neubert, Reinert, v. Noorden, Biernacki, Strauss, and Rohnstein, and 
Stevens found a decrease in haemoglobin of varying degree in all cases. 
In those instances in which the cases have been grouped according 
to Grawitz's system we find the haemoglobin is given as follows: 
Group I.: v. Limbeck, Ewing, and Swan, decreased; Appelbaum, de- 
creased or normal ; Cabot, increased or normal. Group II. : Cabot and 
Swan, reduced; v. Limbeck, Appelbaum, and Ewing, normal or ap- 
proximately so. Group III.: All the writers found it reduced. The 
majority, therefore, found it reduced in Group I., normal in Group II., 
and reduced again in Group III, The amount of reduction varied 
greatly in the different reports. In regard to the high haemoglobin 
finding in Group II. we will refer again in considering the red cor- 
puscles. 

Erythrocytes. — Andral, Sorenson, Pick, v. Noorden, Zappert, 
Biernacki, Strauss and Rohnstein, and Claude and Zaky found a 
constant reduction of the red corpuscles in tuberculosis of various 
stages. Becquerel, Melassez, Laache, Neubert, Reinert, Cabot, and 
Da Costa found the decrease was not constant, as in some of the cases 
the count was normal or above normal. The most marked decrease 
was in a case reported by Melassez, in which the red cells were as low 
as 980,000. Oppenheimer believes the count is normal in this condition 
and only reduced by haemoptysis. Dane, in bone tuberculosis in 
children, found the reds, as a rule, not reduced. Where the cases are 
classified we find the following : Group I. : v. Limbeck, Strauer, 
Grawitz, Halbron, and Swan give a reduction in the red cells ; Stevens, 
Appelbaum, and Ewing believe they are reduced frequently, but may 
be normal. Group II.: All the observers give a normal or increased 
count except Swan and Halbron, the former, however, finding it 
sometimes increased ; Halbron found it constantly decreased. In 
Group III., all the above investigators found the red cells reduced 
except Swan, who found them generally much reduced, but increased 
in 3 out of 15 cases. The evidence in regard to the red corpuscles 
points to the fact that in cases of infiltration or cavity formation with 
hectic fever, especially the latter, they are decreased in number. That 
in cases with cavity formation without fever or complications, and 
occasionally also in the other two groups, we have a normal or even 
increased count. This peculiar and striking condition was explained 



1 68 NATIONAL ASSOCIATION FOR THE STUDY 

by the earlier writers by concentration of the blood, and this has been 
confirmed by later research. 

Different observers have given profuse expectoration, sweating, 
and diarrhoea as causes for the production of this concentration. They 
commonly, however, found cases in which none of the above causes 
were present. The experiments of Gartner and Romer have shed new 
light on the subject and their deductions have been generally accepted. 
They show that the extracts of the tubercle bacillus produced an 
alteration in the relations between the blood-vessels and the tissues in 
the interchange of lymph, with an excess in favor of the tissues. The 
findings of Oliver may also have some bearing upon this phenomenon. 

The most striking feature that we find in all the reports, in con- 
nection with the erythrocytes, is the almost constant disproportion 
between the red cells and the haemoglobin. All the observers men- 
tioned above found a greater diminution of the haemoglobin except 
Oppenheimer and Biernacki, and in addition to those metioned Hayem, 
Huard, Cornil, Hanot, Trousseau, Gilbert, and Labbe have specially 
referred to this very constant finding. Sorenson was the first to point 
out the striking similarity of the blood in tuberculosis and chlorosis 
and Labbe has recently considered the subject in detail. 

In regard to the prognosis based on the blood findings one must 
be very cautious, as numerous observers have found the erythrocytes 
and haemoglobin increase in cases which were developing general 
tuberculosis and advancing toward a fatal termination. 

The literature is very meagre upon the microscopic changes in the 
red corpuscles. Anisocytosis, poikilocytosis, and nucleated reds are 
rarely found, the last being very infrequent even after hemorrhage. 
Maragliano believes the presence of polychromatophilia has an un- 
favorable prognostic significance even in cases otherwise apparently 
favorable. 

Leukocytes. — The results in numerous observations upon the 
number of leukocytes are quite uniform, although the line between 
different groups is not sharply drawn. The earlier observers, Soren- 
son, Halla, and Reinert found the white cells were generally increased, 
and in advanced cases were occasionally low. Pick, Rieder, Warthin, 
V. Jaksch, Galbraith, and numerous others have found the counts in 
pure tuberculosis without complications were always normal or even 
low. Among those who have classified their cases we find that Strauer, 



AND PREVENTION OF TUBERCULOSIS 169 

Appelbaum, Grawitz, and Halbron all found an absence of leukocytosis 
in Group I. The leukocytosis increases in Groups II. and III., de- 
pending upon the degree of mixed infection. The significance of 
leukocytosis in tuberculosis is best summed up in Ewing's conclusion 
that " In pulmonary tuberculosis an increase of leukocytes is usually 
referable to suppurating cavities, advancing pneumonia, severe anaemia, 
or haemoptysis." 

Varieties of Leukocytes : As the actual number of leukocytes has 
proven of so little value from a diagnostic standpoint, especially in 
early cases, an attempt has been made to derive some information from 
the relative number of the different varieties of cells. We are here 
confronted with a great many reports differing greatly, not only on 
account of different groupings of the cases, but also on account of 
different classifications of the leukocytes. Einhorn and Neubert both 
found the polymorphonuclears in excess in various stages. The con- 
sensus of opinion among the more recent observers is that where we 
have leukocytosis in tuberculous cases we have a relative increase of the 
polymorphonuclears. Appelbaum noted an increase of the transitionals 
accompanying the rise of polymorphonuclears. Ewing and Halbron 
found in acute and most chronic tuberculosis the large mononuclears 
in excess. Galbraith found an increase of large mononuclears under 
rich proteid diet, and Strauss and Rohnstein received the impression 
that with the progress of the disease the mononuclears showed a ten- 
dency to fall. 

As the eosinophiles have attracted special attention in tuberculosis 
we have decided to consider them separately. Cabot does not con- 
sider their presence or absence of much significance. All the other 
observers consider them of some prognostic importance. Zappert found 
them decreased in febrile cases with an increase subsequent to, or 
occasionally before, the disappearance of fever. That they were absent 
or only few in number in severe cases was noted by Holmes, Warthin, 
Appelbaum, and Swan. On the other hand, that they were present in 
early cases or reappeared under treatment has been remarked by Claude 
and Zaky, Appelbaum, and Galbraith. Halbron thought they indicated 
the resistance of the organism to the infection. Teichmiiller considered 
their appearance in the sputum in large numbers to be a favorable sign. 

Experimental tuberculosis, to which one would naturally look for 
confirmation of the clinical finding, has unfortunately not proven as 
constant and satisfactory as one could wish. Achard and Loeper found 



I/O NATIONAL ASSOCIATION FOR THE STUDY 

a relative increase of the mononuclears in acute tuberculosis and in 
those cases associated with serous effusion. They found in animals 
inoculated with tubercle bacilli a primary leukocytosis which subsided 
m a few days, being followed by an increase in the mononuclears, 
the eosinophiles reappearing more slowly. Claude and Zaky found 
the eosinophiles appeared in the beginning of the infection and dis- 
appeared rapidly in acutely advancing forms, but remained for a long 
time in the circumscribed fibrous types. They noted especially the 
presence of transitionals and large mononuclears in those cases which 
supported the infection well. 

The injection of tuberculin for diagnostic purposes corresponds 
in its blood changes to the results of experimental tuberculosis. All 
the observers, Bischoff, Rieder, Botkin, and Rille, found a transient 
leukocytosis which was followed by an increase of the esinophiles even 
as high as lo per cent., as reported by Bischoff. This observer also 
noted an increase of mononuclears and transitionals directly after the 
injection. 

The morphological changes in the nuclei and protoplasm of the 
leukocytes have been studied by Holmes and by Arneth. They have 
both attempted to derive information from the degenerative changes 
in the white cells upon which to base not only the prognosis but also 
the diagnosis of tuberculosis. Neusser found his perinuclear granules 
(artefacts) in cases which tended to improve. 

The following is a report of observations on the blood in 39 cases 
of pulmonary tuberculosis, in the wards of the Henry Phipps Institute, 
by the writers, who were assisted in the early part of the work by 
Dr. Nisbet, of Philadelphia. 

In tabulating our cases we have used the Grawitz system, which 
divides the cases into three groups. Group I. : Infiltration, with no 
signs of cavity. Group II. : Those having cavity formation, with little 
or no fever (the original classification also states " and no compli- 
cations " in this group ; as we had only one case of laryngitis, No. 
2056, and three with slight intestinal symptoms, Nos. 2056, 2388, and 
2919, we have included them in this group). Group III.: Cases with 
cavity formation and a hectic type of temperature. We have further 
subdivided each group into " favorable cases," " stationary cases," and 
" fatal cases," under the last heading including two cases which were 
rather rapidly decHning. The stationary cases are also unfavorable, 
as they have not improved under favorable circumstances. 



AND PREVENTION OF TUBERCULOSIS 



171 



HEMOGLOBIN. Original Counts 



I 


II 





I 























I 


I 


3 


3 


3 


I 


3 


3 


I 





3 





3 









III 



II 



III 



40-45 

45-5° 
50-55 
55-60 
60-65 
65-70 
70-75 
7S-80 
80-85 
85-90 

9095 
95-100 



2388 



2957 

2827 3101, 2923, 3060 
2683, 2799, 1694 2056, 3005, 2826 
951 2760, 1975, 2919 

1950, 2984, 2758 2266 

3015, 2674, 2676 
2632, 3065, 2764 



2843 

2660,106,2087,2673 

73 

2737 

2478, 2879 

1554 

388, 3054 
8079 



I Maximum 84 1950 Minimum 66 2827 Average — 74.8 

II " 90 3065, 2764, 2632 " 40 2388 " = 75-6 

III " 100 3079 " 50 2844 " = 70.6 

The haemoglobin in Group I. is quite constantly moderately re- 
duced, averaging 74.8 per cent. In Group II. we find a very slight 
increase in the amount of haemoblobin, in the general average, to 75.6 
per cent. ; in this group, however, we find a great variation in the 
amount, just as we do in Group III. In the latter we find a decrease 
in the average to 70.6 per cent., which would be more marked if it 
were not for three fatal cases which had a very high haemoglobin 
percentage. It will be noted that the difference in haemoglobin in the 
three groups follows very closely the changes in the red corpuscles. 
Erythrocytes. Original Counts in Thirty-nine Cases 



2,500,000-3,000,000 o 
3,000,000-3,500,000 o 
3,500,000-4,000,000 I 



4,000,000-4, 500,000 
4,500,000-5,000,000 



5,000,000-5,500,000 o 

5,500,000-6,000,000 1 o 



II iii: 



951 



2683, 1950, 2827 



II 



III 



3101 



73 

2660, 2843 

'2478,106,2087,2879 

i2672 



3005, 2056, 3060 [ 
,2676 I 
2984, 2758, 2799 2826, 3015, 2923' 



11694 



2266, 2632, 1975 

2674, 3065, 2388^ 

2919, 2957, 2764 1554, 3054, 2737 

2760 3079, 388 



I Maximum 4,930,000 2758 

II " 5,550,000 2760 

III " 5,870,000 3079 



Minimum 3,920,000 951 Average = 4,510,000 
" 3,250,000 3 10 1 " = 4,630,000 

" 2,950,000 73 " = 4,297,000 



172 



NATIONAL ASSOCIATION FOR THE STUDY 
HEMOGLOBIN OR COLOR InDEX. ORIGINAL CoUNTS 





I 


II 


III 


I 


II 


III 


0.30 to 0.40 
0.40 " 0.50 
0.50 " 0.60 
0.60 " 0.70 
0.70 " 0.80 

0.80 " 0.90 

0.90 " 1. 00 






4 

2 
2 




I 

I 
6 

3 
5 
2 







I 
3 

6 
2 
I 




2388 

2957 

1975, 2760, 2826 
2923, 3060, 2919 
3005, 2056, 2266 

2632, 3015, 2674 
3065, 2764 
3101, 2676 






2737 


2683, 2827, 2799 

1694 

2984, 2758 

951, 1950 


2843, 2087, 2672 

2660, 1554, ic6, 388 
3054, 3079 
2478, 2879 

73 









I Maximum 0.95 951 

II " 1.05 2676 

III " 1. 01 73 



Minimum 0.73 2799 
0.42 2388 
0.60 2737 



Average = 0.826 

" = 0.823 

= 0.831 



In considering the number of erythrocytes we find that in Group 
I. the 8 cases ranged between 3,920,000 and 4,930,000 with an average 
of 4,510,000. The 18 cases in Group II. varied between 3,250,00 and 
5,550,000, averaging 4,630,000. In Group III. 13 cases gave from 
2,950,000 to 5,870,000, average 4,297,000. We find, therefore, in 
Group I. a mild anaemia, in Group II. the average is higher, and that 
in Group III, we have two distinct divisions of cases, those with a 
distinctly low count mainly made up of " stationary cases," and a 
group in which the counts are quite high, almost entirely made up of 
" fatal cases." The average for this group is lower than either of the 
preceding groups. In only one instance, Case 1694, was a single nor- 
moblast noted. 

The study of the color index or the relation of the red corpuscles 
to the haemoglobin gives very striking figures. In all three groups 
the color index averages practically the same and this average is dis- 
tinctly below normal. 

In Group I. none of the cases reach normal, ranging between 0.73 
and 0.95, averaging 0.826. In Groups II, and III, we have a much 
wider range in the figures, 3 cases going above i and 3 falling below 
0.70; the average for Groups II, and III, being 0.823 and 0.831 
respectively. 



AND PREVENTION OF TUBERCULOSIS 



173 



Leukocytes. Actual Counts 



I II III 



II 



III 



6,000 to 7,000 
7,000 " 8,000 



8,000 
9,000 
1 0,000 
11,000 
12,000 
15,000 



9,000 
10,000 
11,000 
12,000 
15,000 
20,000 



951, 2799 

1950 

1694 



2984 



2758, 2827 
2683 



Over 20,000 



3060 

2632, 2919 
2266, 2388, 2957 
2676 

2760, 1975 
3015, 2923, 2674 
3005, 3101, 2826 
2056, 3065, 2764 



2672, 388 

1554, 3054, 2879 

2478, 3079 
106,2843,2087,2737 
73 
2660 (empyema) 



I. Maximum 16,440 2683 
II. " 19,200 2056, 2764 

III. " 20,640 2660 



Minimum 6,100 2799 

" 7,600 3060 

8,800 388 



Average = 10,285 
" = 12,772 
" = 14,041 



The leukocytes show marked variation in all the groups, the aver- 
age, however, increasing gradually from Group I. to Group III. We 
found no typical condition for any one group. 

The differential count of the leukocytes in the stained specimen 
gives information which one would expect to be of value in regard to 
the diagnosis of this condition. The findings in the present series of 
cases are rather contradictory and confusing. We found that the 
actual number of each variety was more significant than the relative 
percentage and we have therefore used it in all our considerations. 





Lymphocytes. 


Actual Number in 


Thirty-nine Cases 




I 


II 


III 


I 


II III 


300 to 600 


I 


5 


5 


2799 


3060, 1975, 2660 2879, 1554, 2673 
2923, 2764 3054, 3079 


600 " 900 





4 







3101, 2826, 2919 
2957 




900 " 1200 


I 


4 


4 


3758 


3015; 2266, 3065 2478, 2660, 2843 
2676 ^388 "^ 




1200 " 1500 


3 


2 





2683, 1694, 2827 


2632, 2388 




^J 


1500 " 1800 


2 


2 


I 


951, 1950 


3005, 2056 


2737 





1800 " 2100 

















2100 " 2400 


I 








2984 






2400 " 2700 





I 


I 




2674 


2087 


2700 " 3000 
Over 3000 
Below 1200 








I 






73 








1 






1 06 


25% 


72.5% 


70% 








1200 to 2400 


75 


22.0 


7 








Over 2400 





5-5 


23 









174 



NATIONAL ASSOCIATION FOR THE STUDY 



Lymphocytes. — We found in Group I. the lymphocytes were 
either normal (75 per cent, of cases) or subnormal. In Group II. the 
majority of cases (72 per cent.) showed a count below normal, as they 
did also in Group III. (70 per cent.). In Group II. they were in- 
creased in 5 per cent., and in Group III. in 23 per cent, of the cases. 
We have not been able to correlate these rather contradictory findings, 
except that the majority of the fatal cases were among those showing 
a lower count. 



EosiNOPHH^s, Polymorphonuclears. Actual Number in 
Thirty-nine Cases 





I 


II 


III 


I 


II 


III 


Below 100 


I 


9 


6 


951 


3005, 2632,"2266 

3IOI, 2760, 3015 

2919, 2388, 2676 


2478, ISS4, 2843 
2672, 2879, 73 


^ r ICO to 200 


I 


6 


2 


1694 


3060, 2826, 2674 


3054, 3079 


a. 










3065, 3957, 2764 


■ 


200 " 300 
I 300 " 400 


3 

2 





2 


2984, 2827, 2799 
2683, 1950 




2737, 388 


I 


3 


1975 


2660, 106, 2087 


400 " 500 

















Over 500 


I 


2 





2758 


2923, 2056 




Below 100 


12.5% 


50% 


46% 








100 to 400 


75-0 


39 


54 








Above 400 


12.5 


II 












Polymorphonuclear Neutrophiles in Thirty-nine Cases 
Actual Numbers 



II 



III 



II 



III 



3,000 to 6,000 

6,000 " 9,000 

9,000 " 12,000 

12,000 " 15,000 

15,000 " 18,000 
Below 6,000 

6,000 " 12,000137.50 

12,000 " 18,000} o 



951, 195a 12957, 2632, 3060 

2799, 2984 I2266 

I 

2888, 2919, 2676 



2758 
2827, 2683 



62.50% 22.22% 7-69% 
44.44 161.53 
33-33 133-76 



2672, 2879, 3054 



2760, 1975 1554 

3015, 2923, 2647 2737, 3079, 2478 

I106 
3101, 3005, 2826 73, 2843, 2087 
2056, 3065 



2764 



2660 



AND PREVENTION OF TUBERCULOSIS 
Transition ALS. Actual Number in Thirty-nine Cases 



175 





I 


II 


III 


I 


II 


III 


Below 


300 


I 








1950 






300 to 


600 


2 


I 





951, 2758 


2266 




600 " 


900 


I 


S 


5 


2799 


2923, 1975, 3060 
2919, 2388 


73, 2672, 2879 
3079, 1554 


900 " 


1200 


3 


s 

6 


2 


2683, 2827, 1694 


2826, 2632, 3015 ic6, 2087 

2764, 2957 

3101, 2760, 3005 3054, 388 

























3065, 2674, 2676 


1500 " 


2100 


I 


I 


3 


2984 


2056 


2478, 2737, 2660 


Over 


2100 





, 


I 






2843 


Below 


300 


"•5% 














300 to 


1200 


75-0 


61% 


54% 








Over 


1200 


12.S 


39 


46 









Large Mononuclears. Thirty-nine Cases. Actual Numbers 





I 


II 


III 


I 


II ! Ill 


Below 


300 


3 


7 


2 


951, 2984, 1694 


1 

2760, 3005, 2632|2672, 388 














2674, 3065, 2919 
















2676 




300 to 


600 


I 


I 


9 


2799 


3015 


2478, 2660, 2087 
106, 2879, 73 
2737, 3054, 3079 


600 " 


900 


I 


2 


I 


2827 


2923, 3060,23881554 


900 " 


1200 


I 


4 


I 


1950 


3101, 2826, 2266 2843 














2764 




1200 " 


1500 
1800 





I 






1975 
2056, 2957 




1500 " 


I 


2 





2758 




1800 " 


2100 


I 








2683 






Below 


300 


37-5% 


38.5% 


1 5-5% 








300 to 


600 


12.5 


5-5 


69.0 








600 " 


1200 


25.0 


38.5 


I5-S 








Over 


1200 


25.0 


17.S 












EosiNOPHiLE Polymorphonuclears. — Here our findings were 
more definite. In Group I. we found 87.5 per cent, of all cases were 
normal or above normal. In Group II., 50 per cent, of cases were 
below normal, while in Group III. the eosinophils were never above 
normal. In only 3 cases of all three groups were they found above 
500, and they were all favorable. 



176 



NATIONAL ASSOCIATION FOR THE STUDY 



The estimation of the polymorphonuclears, transitionals, and large 
mononuclears showed nothing of special significance. 

In 2 cases, Nos. 2683 and 73, in which there was a leukocytosis 
of 16,000, there was a single myelocyte noted. 

In 25 of the above cases it was possible to make a second count 
while the patient was still in the hospital. The second counts were 
made after an interval of two to two and one-half months. The du- 
plicate counts being made to see if there were any changes in the 
blood upon which one could base the prognosis. Of these cases 4 
were in Group I., 16 in Group II., and 5 in Group III. 

Cases remaining under observation. Increase and decrease re- 
ferring to second count in comparison to first count. Counts made 
about two or three months apart. 

Erythrocytes 



Increased 



Decrease 


Increase 


1694 


75% 


2760 


94 


2737 


80 



Decrease 



III 



951, 2683, 1950 

3101, 3005, 2826, 2056, 3015, 2923, 2632, 3060 

1975, 2266, 3065, 2919, 2674, 2676, 2764 
2660, 1 06, 1554, 2843 



25% 
6 



The erythrocytes generally increase under treatment; this is true 
of the favorable and unfavorable alike, the increase occurring in those 
which are not improving as well as in those which are apparently doing 
very well. In the first group, however, it was noted that the one case 
which decreased was the only stationary one in that group and in the 
third group the only one to decrease was the most unfavorable one in 
that class. In Group II., however, they almost all increased regardless 
of the patient's general condition. 









HAEMOGLOBIN 










Increased 


No change 


Decreased 


Increase 


No change 


Decrease 


I 




1694 I951, 2683, 1950 





25% 


75% 


II 




1975, 3005 '2760, 2826, 2056, 3015, 2632 

2923, 3101 3060, 2266, 2674, 3065, 2676 
2919 2764 





31 


69 


III 


2737 


2660, 2843 
106 


1554 


20% 


60 


20 



The haemoglobin, as a rule, either remained stationary or de- 
creased regardless of any improvement on the part of the patient. The 



AND PREVENTION OF TUBERCULOSIS 



177 



only case in which the haemoglobin increased was the most unfavor- 
able one in Group III. 

HEMOGLOBIN Index 





Increased 


No change 


Deceased 


Increase 


No change 


Decrease 


I 


1694 




951, 2683, 1950 


25% 





75% 


11 






3101, 2760, 3005, 2826, 2056 
3015, 2928, 2632, 3060, 1975 
2266,' 2674, 3065, 1 91 9, 2676 
2764 








100 


III 




2737 


2660, 1554, 106, 2843 





20% 


80 



As one would naturally expect in a condition where the red cells 
increased in number without a corresponding increase in haemoglobin, 
we found an almost constant decrease in the color index. 

Leukocytes 





Increased 


Decreased 


Increase 


Decrease 


T 


951, 2683, 1950, 1694 

3101, 3015, 2922, 2632, 3060 

1975, 2266, 2919 




100% 
56 







II 
III 


2760, 3005, 2826, 2056, 3065 

2674, 2676, 2764 

2660, 1554, 106, 2843, 2737 


50% 









The leukocytes present a rather peculiar condition and one which 
is contrary to the usual findings. In Group I. every case showed an 
increase of the leukocytes under treatment. One-half the cases in 
Group II. present an increased count and one-half a decrease, in the 
latter being the majority of the unfavorable cases, and only one sta- 
tionary case being found in the first half. In Group III. in every case 
the leukocytes were found to have decreased. 

Lymphocytes. Comparative Counts 





Increased 


Decreased 


Increase 


Decrease 


I 


951, 2683, 1950, 1694 

3101, 2826, 2056, 2923, 3060 

1975, 2266, 2674, 3065, 2764 
2660, 2843 


* 


100% 
62.S 

40 





II 
III 


2760, 3005, 301a, 263a, agig 

2676 

106, 1554, 2737 


37.5% 
60 



Lymphocytes. — We feel that in the actual number of this form 
of leukocyte we have perhaps one of the best indications upon which 
to base the prognosis, although it is not absolute. In Group I. we 
found an increase of 100 per cent., in Group II. only 62.5 per cent, 
increased, while in Group III. we find only 40 per cent, showed ?n 
increase in the number of lymphocytes. 



178 



NATIONAL ASSOCIATION FOR THE STUDY 



EosiNOPHiLE Polymorphonuclears 



Increased 



Decreased 



Increase 



Decrease 



I 
II 

III 



951, 1950, 1694 

3005, 3015, 2923, 2632, 3060 

2674, 2919, 2764 
1554 



2683 

3101, 2760, 2826, 2056, 1975 

2266, 3065, 2676 

2660, 2843, 106, 2787 



75% 
50 



25% 
50 

80 



EosiNOPHiLES. — This variety, in a general way, followed the 
same course as the foregoing. In Group I. 75 per cent, increased ; in 
Group II., 50 per cent, and in Group III., 20 per cent, of the patients 
showed an increase of the eosinophiles, the one case being a stationary 

^^^' Neutrophile Polymorphonuclears 



Increased 



Deceased 



Increase Decrease 



I 
II 

III 



951, 2683, 1950, 1694 

3101, 3015, 2923, 2632, 3060 

1975, 2266, 2919, 26761 
2843I 



2760, 3005, 2826, 2056, 2674 

3065, 2764 

2660, 106, 1554, 2737 



100% 
56 



44% 
80 



Neutrophile Polymorphonuclears. — These follow exactly the 
increase or decrease in the number of leukocytes except in Cases 2843 
and 2676, and in the latter one of these the increase in this variety was 
less than 100. large Mononuclears 





Increased 


Decreased 


Increase 


Decrease 


T 




951, 2683, 1950, 1694 
2826, 2056, 3060, 2674 

2660, 106, 2843, 2731 



75% 

!'20 


100% 
25 

80 


II 
III 


3101, 2760, 3005, 3015, 2923, 2632 

1975, 2266, 3065, 2919, 2676, 2764 
1 554 



Large Mononuclears. — This variety decreased in all of the first 
group. In Group II., in 75 per cent, of the patients, they increased 
regardless of the character of the case, and in Group III. i case out 
of the 5, which was a stationary case, showed an increase. 

Transitional Forms 





Increased 


Decreased 


Increase 


Decrease 


T 


951, 2683, 1950, 1694 
2923, 3060, 1975 




100% 

19 







II 
TIT 


3101, 2760, 3005, 2826, 2056, 3015 

2632, 2266, 2674,3065, 2919,2676, 2764 
2843, 106, 2660, 1554, 2737 


81% 
100 









^ Only cases in which the polys, did not correspond to increase or decrease 
of leukocytes, q. v. 



AND PREVENTION OF TUBERCULOSIS 1 79 

Transitionals. — These showed a very interesting change. In 
Group I. they were increased in every case, while in Group III. every 
case showed a decrease. Group II. showed a decrease in 81 per cent, 
of cases. All those in this group that showed an increase of this form 
were improving cases. 

From these examinations we would draw the following con- 
clusions, being fully convinced, however, that the series is too limited 
in number and the field covered too narrow to draw deductions which 
could be considered by any means final: 

1. In pulmonary tuberculosis without cavity formation a mild 
anaemia, with a decrease in erythrocytes and a relatively greater de- 
crease in haemoglobin, is constant. 

2. From the standpoint of prognosis an increase of the erythro- 
cytes, in cases without cavity formation, is of favorable significance. 

3. In advanced cases a decrease of the leukocytes is of unfavor- 
able import. 

4. In our investigations we have received the impression that the 
actual increase of lymphocytes seems to correspond to the increase of 
resistance on the part of the organism to the tuberculous infection, but 
further study is required to confirm this deduction. 

5. The transitionals seem to follow the same rule as the lympho- 
cytes in this regard. 

6. At the beginning of the investigation the eosinophils seemed 
to increase with the patient's improvement, but further study did not 
support this view. 

REFERENCES 

1. Achard and Loeper. Comptes-rendus de la biologic, 1901. 

2. Andral et Garanet. Annales de chimie et de physique, 1840, tome 
Ixxv. p. 225. 

3. Andral, Garanet et Delafond. Ibid., 1842, p. 304. 

4. Appelbaum, L. Berliner klin. Woch., January 6, 1902. 

5. Arneth, J, Mtinch. med. Woch., March 21, 1905, Bd. Hi. No. 12. 

6. Arneth, J. Ibid., 1904, Bd. li. No. 25. 

7. Barbacci, O. Centralblatt f. med. Wissenschaften, 1887, No. 35. 

8. Becquerel et Rodier. Recherches sur la composition du sang., Paris, 
1844 (Memoires Acad, des Sciences, November, 1844.) 

9. Bergeron, A. Presse medicale, 1904, No. 17. 

10. Bierfreund. Arch. f. klin. Chirurgie, Bd. xi. p. i. 

11. Biernacki. Zeit. f. klin. Med., Bd. xxiv.. Heft 5 and 6. 

12. Bischoff. Inaug. Dissert, Berlin, 1891. 

13. Botkin. Deut. med. Woch., 1892, No. 15, p. 321. 



l8o NATIONAL ASSOCIATION FOR THE STUDY 

14. Brown, Thomas R. Medical News, June 13, 1903. 

15. Cabot, R. C. Clinical Examination of the Blood, 1904. 

16. Claude and Aly-Zaky. Gaz. hebdom. de med. et de chir.. May 15, 1902 : 
Revue de la tuberc, July, 1902, tome ix. No. 2. 

17. Coles, Alfred C. The Blood : How to Examine and Diagnose its 
Diseases, 1902. 

18. Cornet. Tuberculosis, Nothnagel Series. 

19. DaCosta, J. C. Clinical Hemology, 1905. 

20. Dane, J. Boston Medical and Surgical Journal, May 28, 1896. 

21. Dehio. St. Petersburger med. Woch., 1891, No. i. 

22. Ehrlich and Lazarus. Die Anamie, Nothnagel's Spec. Path, und 
Therap., vol. viii. 

23. Einhorn. Inaug. Dissert., Berlin, 1884. 

24. Ewing. Clinical Pathology of the Blood, 1903. 

25. Fenoglio. Wiener med. Jahrbiicher, 1882, p. 635. 

26. Galbraith. British Medical Journal, March 14, 1903. 

27. Gartner and Romer. Wiener klin. Woch., 1892, No. 2, p. 22. 

28. Gnezda. Inaug. Dissert., Berlin, 1886. 

29. Grawitz. Klinische Pathologic des Blutes, Berlin, 1902. 

30. Haberlin. Miinch. med. Woch., 1888, No. 22. 

31. Halla. Prager Zeit. f. Heilkunde, 1883, Bd. iv. 

32. Hayem. Du sang et ses alterations anatomiques, Paris, 1889. 

33. Haidenhain. Pfliiger's Arch., Bd. xlix. p. 209. 

34. Halbron. Revue de la tuberc, 1903, p. 319. 

35. Hills, F. L. Boston Medical and Surgical Journal, 1901, vol. cxxxix. 

P- 542. 

36. Holmes. A Study of the Blood in Tuberculosis, Medical Record, Sep- 
tember 5, 1896; ibid., March 13, 1897; Journal of the American Medical As- 
sociation, 1897, vol. xxix. p. 828. 

37. V. Jaksch. Zeit. f. klin. Med., 1893, Bd. xxiii. Nos. 3 and 4. 

38. Laache. Die Anamie, Christianna, 1883. 

39. Labbe. Bull, et mem. d'hop. de Paris, 1904, tome xxi. p. 989-1003. 

40. Lacker. Wiener med. Woch., 1886, No. 27, p. 950. 

41. Leichtenstern, Otto. Untersuchungen iiber den Hamoglobingehalt des 
Blutes, Leipzig, 1878. 

42. Levaditi, C. Le leucocyte et ses granulations, Paris, 1902. 

43. Liebermeister. Deut. med. Woch., 1888. 

44. V. Limbeck. Grundriss einer klinischen Pathologic des Blutes, 1892. 

45. Melassez. Bull. Soc. anatomique, April 17, 1874, p. 287. 

46. Maragliano. Congress f. innere Med., Leipzig, April 20-23, 1892. 

47. V. Nasse. Wagner's Handworterbuch der Physiologic, 1842, Bd. i. 
p. 138. 

48. Neubert. St. Petersburger med. Woch., 1889, No. 32. 

49. Neusser. Ueber einen besonderen Blutbefund bei uratischer Diathese, 
Wiener klin. Woch., 1894. 

50. V. Noorden, K. Die Bleichsucht, Nothnagel's System, Bd. viii., Th. 2, 
p. 67. 

51. V. Noorden. Lehrbuch des Stoffwechsels, 1893. 

52. Oliver. Croonian Lecture, Lancet, June 27, 1896. 

53. Oppenheimer. Deut. med. Woch., 1889, Nos. 42-44. 

54. Osterspy. Berl. klin. Woch., 1892, No. 12, 



AND PREVENTION OF TUBERCULOSIS l8l 

55. Pick, G. Prager med. Woch., 1890, No. 24. 

56. Quinquaud. Comptes-rendus Acad, de Science, August 1873, tome 
Ixxvii. p. 447. 

57. Reinert, Emil. Die Zahlung der Blutkorperchen and deren Bedeutung 
f. Diagnose und Therapie, 1891. 

58. Rieder. Beitrage zur Kenntniss der Leukocytosis, 1892. 

59. Rille. Monatshefte f. prakt. Dermatologie, 1893, Bd. xvi. p. 188. 

60. Samuel. Blut-Anomalien, Eulenburg's Realencyclopadie der gesammten 
Heilkunden, 3. Aufl., Bd. iii. p. 574. 

61. Sorenson. Inaug. Dissert., Copenhagen, 1876. Reviewed in Jahresbe- 
richt der Anatomie und Physiologie, 1878, Bd. v. Abth. 3, p. 192. 

62. Stein und Erbmann. Deut. Arch. f. klin. Med., Bd. Ivi., Heft 3 and 4. 

63. Strauss, M. L. Medical Record, July 26, 1902, vol. Ixii. p. 133. 

64. Strauer. Zeitschr. f. klin. Med., Bd. xxiv. p. 295 ; Deut med. Woch., 
1893. 

65. Strauss and Rohnstein. Die Blutzusammensetzung bei den verschiede-. 
nen Anamien, Berlin, 1901. 

66. Striimpell. Miinch. med. Woch., 1892, p. 50. 

67. Swan, J. M. Journal of the Am. Medical Association, March 12, 1904. 

68. Teichmiiller, W. Deut. Arch. f. klin. Med., Bd. Ix. pp. 563-579. 

69. Vierordt. Die quantitative Spektralanalyse, Tiibingen, 1876, p. 60. 

70. Waldstein. Berl. klin. Woch., 1895, No. 17. 

71. Warthin, A. S. Medical News, 1896, vol. Ixviii. p. 89. 

72. V. Wilcken. Dissert. Dorpat. 

yZ' Wiskeman. Zeit. f. Biologic, 1876, Bd. xii. p. 442. 
74. Zappert. Zeit. f. klin. Med., 1893, Bd. xxxiii. 



DISCUSSION ON THE PAPER BY DRS. ULLOM AND CRAIG 

Dr. Wm. H. Welch, Baltimore: It is very interesting to note 
that the increase in the large and small leucocytes is important. I 
would like to know whether the authors included blood conditions in 
acute inflammatory diseases. No doubt there are certain cases, such 
as for example of typhoid fever, preventing polynuclear leucocytosis. 

Dr. F. A. Craig, Philadelphia: The only point which would 
correspond to what Dr. Welch has said occurred but once in our experi- 
ments and that was in a case which was complicated by empyema. 
In this case we had the highest leucocytosis that we had anywhere. 

Dr. M. B. Stanton, Philadelphia : One especially important point 
in these cases was the low color index. A Frenchman has stated that 
in most cases the colors are really indications of latent or incipient 
tuberculosis. 



TUBERCULOSIS OF THE THORACIC DUCT AND 
ACUTE MILIARY TUBERCULOSIS 

By Warfield T. Longcope^ M. D. 

Philadelphia 

(From the Ayer Clinical Laboratory, Pennsylvania Hospital) 



Tuberculosis of the thoracic duct has been recognized for over a 
hundred years. In 1798 the condition was discovered accidentally by 
Astley Cooper/ who described the lesions quite accurately and moreover 
interpreted his findings correctly inasmuch as he considered that the 
great lympathic vessel was the seat of scrofulous disease. Among the 
earlier writers AndraP is also credited by some with having described 
the same condition, but his notes are so vague that the correctness of 
the assumption is doubtful. It was, however, Ponfick^ who really first 
drew special attention to thoracic duct tuberculosis and emphasized 
its connection with acute miliary tuberculosis, though he did not con- 
sider it as the cause of the generalized process. His original communi- 
cations were made in 1877, ^^^ during the next year Weigert* reported 
his cases of vein tuberculosis and announced his conception of the origin 
and pathogenesis of acute miliary tuberculosis. In 13 such cases he 
found foci of tuberculosis in the veins in 10 and of the thoracic duct in 
two. From the nodules in the veins and in the thoracic duct he believed 
that the poison (this was prior to the discovery of the tubercle bacillus) 
was swept into the general circulation and thereby gave rise to the gen- 
eralized acute process. According to Weigert, before a focus in a vein 
or lymph channel can be considered as the point of origin of the acute 
process at least four conditions must be fulfilled : 

I. The tubercle in the wall of the vein or duct must be older than 
the miliary nodules scattered through the organs of the body. 

^Medical Records and Researches, 1798, Vol. I, p. 86. 
'Arch. Gen. de Med., 1824, Tome VI, p. 508. 
^Berlin, klin. Wochen., 1877, No. 46, p. 673. 

* 51. Naturforscker-Versammlung, 1878, quoted from Virch. Arch. 1882, 
Bd. 88, p. 307. 

182 



NAT. ASS'n for study AND PREV. OF TUBERCULOSIS 1 83 

II. The tubercle must be situated in a vein or large lymph vessel 
which is patent. 

III. The poison must reach the surface of the nodule, i. e., com- 
municate with the lumen of the vessel ; a condition which is usually if 
not always satisfied in lesions of the thoracic duct. 

IV. The tubercle must not be situated in the portal vein. 
Following Weigert's original work many investigators published 

observations which upheld and confirmed his doctrines. Not only were 
the tuberculous nodules of veins described in connection with general 
acute tuberculosis, but thoracic duct tuberculosis, in which we are es- 
pecially interested, was noted. 

Stilling,^ in 1882, found tuberculosis of the thoracic duct in 5 of 
18 cases of acute miliary tuberculosis, while Meissels,'* in 1884, pub- 
lished the descriptions of 8 cases of acute miliary tuberculosis in some 
of which tuberculosis of the thoracic duct occurred. In the same year 
Koch' in his splendid work on tuberculosis reports 11 cases of acute 
miliary tuberculosis in two of which he mentions an involvement of 
the thoracic duct. Koch, of course, first demonstrated the presence 
of tubercle bacilli in the lesions of the veins and lymph channel and 
pointed to the actual dissemination of bacilli, the poison of Weigert, 
by way of the general circulation to the various organs of the body. 
Subsequently Weigert* in his own specimens confirmed Koch's 
work regarding the presence of bacilli in the nodules in the veins and 
thoracic duct. 

Later Brosch"* in a study of 24 cases of miliary tuberculosis men- 
tions an examination of the thoracic duct in 17 instances, and 9 times 
tuberculosis was discovered in this vessel. In 6 instances the tuber- 
culosis was caseous in type. He emphasized the relationship between 
involvement of the serous cavities and of the duct, and concludes that 
the infection is carried to the duct from the "peritoneum and pleurae 
and not through the lymph nodes. 

Hanau,® Sigg,'' Helbing® and others have reported still other cases 
of thoracic duct infection, while more recently Benda® has called par- 

* Virch. Arch., 1882, Bd. 88, p. in. 

* Wiener med. Wochen., i?^4, No. 39, p. 50, 

' Mittheil. aus dem Kaiserlichen Gesundheitsatnte, 1884, Bd. 2, p. 24. 

* Deut. med. Wochen., 1883, No. 24, p. 349. 
'Diss., Heidelberg, 1889. 

* Virch. Arch., 1887, Bd. 108, p. 221. 
^ Quoted from Benda. 

* Verh. d. Berl. med. Gesellschaft, itS99, Bd. XXX, ii, p. 153. 
*Verh. d. Berl. med. Gesellschaft, 1899, Bd. XXX, ii, p. 259. 



184 NATIONAL ASSOCIATION FOR THE STUDY 

ticular attention to the condition. In a very large proportion of cases 
of general miliary tuberculosis, 12 out of 19, he found tuberculous 
disease of the thoracic duct and believes the localization of the process 
in this situation more than in any other gives rise to acute miliary 
tuberculosis. Benda considers that the primary infection of the vessel, 
whether it be vein, artery or thoracic duct, attacks the intima. The pro- 
cess arises by a deposition of tubercle bacilli upon the intima of the 
vessel. Naturally this view has been frequently opposed. 

Weigert's work and that of his followers has been criticized and 
his views strenuously contested by Wild.^ Though not denying the 
occasional occurrence of macroscopic lesions in the veins and thoracic 
duct Wild explains the origin of acute military tuberculosis differently 
from Weigert. He does not believe that the general process arises from 
an overwhelming invasion of the blood by tubercle bacilli liberated 
from a single focus of disease situated in a vein or the thoracic duct. 
In his conception the point of entry of the bacilli into the blood stream 
is hidden and obscure. By undiscoverable routes the bacteria enter the 
circulation in small numbers, and either here or in the organs multiply 
to produce the general infection. Though Wild is upheld in his views 
by Ribbert,^ whose pupil he is, his work has not been generally con- 
firmed and his following is small. Weigert* naturally confutes Wild's 
conclusions at every step. 

From a short review of the literature it will be seen that more and 
more importance is being attached to tuberculosis of the thoracic duct 
as a point of origin of the general acute form of tuberculosis, while the 
lesions of the veins, particularly the pulmonary veins, which at first 
received so much attention, are now becoming of secondary importance. 
Silbergleit,* however, in a recent discussion of the subject describes 
only 5 cases of duct infection among 23 well studied cases of general 
acute miliary tuberculosis, though either vein or duct tuberculosis oc- 
curred in 95.6% of the total number. It may be said, however, that 
to exclude a lesion in the thoracic duct the vessel must be dissected from 
the receptaculum chyli to its entrance into the left subclavian vein, 
since in certain cases only a solitary tuberculous nodule may be found 
in the extreme upper portion. 

In the following 25 cases of tuberculosis in which the process was 

* Virch. Arch., 1897, Bd. 149, p. 65. 

' Deut. med. Wochen., 1897, No. 53, p. 841. 

* Deut. med. Wochen., 1897, Nos. 48, 49, pp. 761 and 780. 

* Virch. Arch., 1905, Bd. 79, p. 283. 



AND PREVENTION OF TUBERCULOSIS . 185 

more or less generalized especial attention was paid to a study of the 
thoracic duct as a possible point of origin for the generalized process. 
Eighteen of these cases occurred at the Pennsylvania Hospital and 
seven at the Johns Hopkins Hospital. For this latter series I am 
greatly indebted to Dr. William G. MacCallum, who placed the records 
of the autopsies at my disposal. The dissections of the ducts in most of 
the cases from the Johns Hopkins Hospital were made by Dr. Eugene 
Opie. 

Case I. — Male, aet. 45, laborer, white, admitted to the Pennsylvania 
Hospital September 20th, 1902, in delirium. Twenty-four years ago patient had 
pneumonia and for years has had a slight cough. For two weeks before ad- 
mission he complained of weakness, and pain in abdomen. For a few days he 
had been acutely ill with delirium which his friends ascribed to excessive drink- 
ing. Examination showed no pronounced lesions in lung. Kernig's sign was 
present 9-30. Death lo-i. Temperature below 101°, respiration 36-40, pulse 
120-136. 

Autopsy October ist, 1902, No. 303. 

Anatomical Diagnosis: Chronic pulmonary tuberculosis, generalized acute 
miliary tuberculosis, tuberculous basal meningitis with tubercles over ependyma, 
tuberculous ulceration of ileum, tuberculosis of thoracic duct. 

Abstract of Autopsy Notes: The upper lobe of right lung is scarred and 
contracted by old fibrous bands. There are no cavities or large caseous areas. 
The lung is seeded with minute tubercles. The left lung also shows some scarring 
and contraction of upper lobe, but less marked than the right. Like the right 
lung the cut surface is seeded with small tubercles most numerous in the upper 
lobe. Spleen, liver and kidneys do not show microscopic tubercles. The small 
intestines are the seat of a fairly extensive tuberculous ulceration, some of the 
ulcers being quite large. The retroperitoneal and mesenteric lymph glands are 
much enlarged, firm and gray on section. 

Thoracic Duct: The thoracic duct is thickened throughout its length and 
the wall near the receptaculum chyli measures about 2 mm. in thickness and 
14 cm. in circumference. Enlarged lymph nodes are attached to it throughout 
its lengfth. On opening the duct the surface is seen to be simply covered with 
fine raised granules which can be distinctly felt. 

Microscopical Examination: Tuberculosis of king. No tubercles found 
in spleen, liver or kidney. Tuberculosis of meninges and tuberculous ulcers of 
intestines. 

Case II. — Male, colored, set. 29, laborer, admitted to Pennsylvania Hospital 
on August 17th, 1902. Entered with wound in back about 5th dorsal vertebra, 
operation, laminectomy, followed by paralysis of lower extremities. Wound 
discharges pus and patient has high temperature. 8-21 complains of cough ; 
9-6 developed bad sores; 9-14 cough again; 9-30 wound gradually healing, cough 
continues, 10-13 temperature very irregular with frequent chills; 11-18 cough 
much worse, extreme emaciation. Death 11-18. 

Autopsy November 19, 1902, No. 322. 

Anatomical Diagnosis: Chronic pulmonary tuberculosis with cavity forma- 
tion of left side. Generalized miliary tuberculosis; tuberculous ulcers of in- 



1 86 NATIONAL ASSOCIATION FOR THE STUDY 

testines; tuberculosis of mesenteric lymph nodes; tuberculosis of thoracic duct; 
fracture of arch of 7th dorsal vertebra ; transverse myelitis ; chronic pachymenin- 
gitis. 

Abstract of Autopsy Notes: The right lung is sprinkled with small 
tubercles. In the upper lobe of left lung there is a large cavity 8 cm. in 
diameter with irregular corded walls. Three . smaller cavities are seen. The re- 
mainder of lung is sprinkled with small tubercles and caseous areas. No micro- 
scopic tubercles are found in spleen, liver or kidneys. The small intestines show 
many small ulcers, most of them about the size of a grain of wheat. The 
mesenteric lymph glands are enlarged, firm and caseous. 

Thoracic Duct: The receptaculum chyli is slightly enlarged. On opening 
the thoracic duct the walls are found to be thickened, and the inner surface 
is distinctly roughened. Close inspection shows that the roughening is due to 
fine raised white glistening points thickly seeded along the duct. 

Microscopical examination shows tuberculosis of the lungs with great 
numbers of solitary tubercles in the spleen, liver and thoracic duct, large areas 
of coagulation necrosis in the kidney and mesenteric lymph glands, tuberculous 
ulceration of intestines. 

Case III. — Male, set. 22, laborer, white, admitted to Pennsylvania Hospital 
March 13th, 1903. Patient is a spare young man, gives history of 20 days' ill- 
ness with headache, pain in abdomen, considerable cough, expectoration and 
fever. Lungs show harsh expiration and sibilant rales. Examination of other 
organs negative. 3-14 leucocytes 2,400. During illness breath sounds are 
harsh and lungs show fine rales. Much cyanosis, continuous even temperature 
between I02°-I04°. 3-26 convulsion. Death March 26th. 

Autopsy March 27, 1903. 

Anatomical Diagnosis: General acute miliary tuberculosis, tuberculosis of 
mesenteric lymph nodes, early tuberculous ulceration of ileum and colon, tuber- 
culosis of thoracic duct. 

Abstract of Autopsy Notes: Both lungs are filled with small tubercles 
varying from ^ to 2 mm. in diameter. They are most numerous at the apices. 
There are no chronic lesions. Spleen is densely seeded with fine glistening 
points, but none can be made out in liver. Many small yellow tubercles in 
kidneys. Intestines show many small shallow ulcers 3-5 mm. in diameter. The 
mesenteric lymph nodes are very large, pale and soft. One, the size of a walnut, 
is filled with necrotic material. The retroperitoneal lymph glands are also very 
large and soft but deep red in color. 

Thoracic Duct: On opening the receptaculum chyli 2 or 3 c.c. of a thin 
bloody fluid escape. The walls of the structure are simply sanded with small 
glistening gray and yellow dots which stand up above the surface and occasionally 
measure from i to 2 mm. in diameter. In the thoracic portion of the duct 
groups of the same granules cover the walls and extend into the lumen. Through- 
out its length the duct admits the knob of a pair of scissors 2^ mm. in diameter. 
In places, however, it is difficult to pass the knob. Just at the point where the 
duct runs beneath the arch of the aorta, before the duct is opened a yellow 
mass about 2 mm. in diameter can be seen on the inner surface of its wall. On 
opening the duct at this point small soft caseous masses measuring about 2 mm. 
in diameter project into the lumen. The wall about is sprinkled with minute 
gray points. At the receptaculum chyli there is some slight thickening of the 
wall, but elsewhere it is thin and delicate. 



AND PREVENTION OF TUBERCULOSIS 1 87 

No foci or tuberculosis can be seen in stomach, esophagus, urinary bladder, 
prostate, seminal vesicles. Microscopical examination shows small single and 
conglomerate tubercles in lungs, liver, spleen, kidney, adrenals and heart, tuber- 
culous ulcers of intestines and a chronic tuberculosis with caseation and necrosis 
of mesenteric lymph no^es. 

Thoracic Duct: Smear from the fluid in the duct shows myriads of tubercle 
bacilli. Sections made near the receptaculum chyli show a thickened wall covered 
with foci of necrotic material. Some of these are quite large and jut out into 
the lumen. Some are very minute and form only a slight projection which is 
covered by endothelium. The wall of the duct as well as the fat about is in- 
filtrated with epithelioid cells and small round cells. In the wall of the re- 
ceptaculum chyli there are many subendothelial areas of necrosis surrounded by 
epithelioid cells. A few contain giant cells. Sections stained in carbol fuchsia 
show great numbers of tubercle bacilli situated in the caseous areas. 

Case IV. — Male, aet. 39, colored, admitted to Pennsylvania Hospital 
April 26th, 1903. Patient is a thin negro. He was taken sick 2 weeks ago with 
cough. Over right lung fine crepitations and rales; examination of other organs 
negative. 4-28, leucocytes 2,900. Patient grew rapidly worse and died on 
May 4th. Temperature throughout illness fairly regular between 102° and 104°. 
Respirations rapid, 34-40; pulse 120-140. 

Autopsy May 5th, 1903, No. 406. 

Anatomical Diagnosis: General acute miliary tuberculosis; caseation of 
mesenteric lymph glands; tuberculosis of the ependjmia of lateral ventricles; 
tuberculosis of the thoracic duct. 

Abstract of Autopsy Notes: Lungs are seeded with minute tubercles and 
do not show any chronic lesion. Spleen, liver and kidneys show many small 
tubercles; no ulcers can be discovered in the intestines. The mesenteric lymph 
nodes are large, some averaging from 2-3 cm. in diameter ; they are usually 
firm and on section show areas of coagulation necrosis. The retroperitoneal 
lymph nodes are also enlarged but not as large as the mesenteric. They are 
studded with small tubercles. The stomach, esophagus, pancreas, urinary blad- 
der, prostate, seminal vesicles and testes show no tuberculosis. 

The thoracic duct is large throughout its length and contains a moderate 
amount of milky fluid. On opening it the walls are seen to be studded at 
irregular intervals with small soft raised opaque yellow points the size of a pin- 
head, or with tiny dots. The walls are thickened. Just at the entrance of the 
receptaculum chyli into the duct there is a constriction, while beyond, the re- 
ceptaculum is greatly distended with fluid. It measures about 4 cm. in length 
and 2 cm. in width- On cutting through the constriction the wall of the duct is 
seen to be thickened at this point and practically occluding the duct is a soft 
mass of caseous material. The receptaculum like the duct is studded with 
minute tubercles. 

Microscopical examination reveals single and conglomerate tubercles of 
lungs, liver, spleen and kidneys with caseation of the mesenteric lymph glands. 

Thoracic Duct: The walls are greatly thickened and in many sections are 
covered with masses of necrotic material. About this necrotic lining the wall 
is densely infiltrated with lymphoid cells and epithelioid cells occasionally as- 
suming an arrangement suggestive of tubercle, but no typical tubercles are 
seen. The surrounding fat is infiltrated with the same cells and some new 
connective tissues. Tubercle bacilli are seen in enormous numbers in smears 



1 88 NATIONAL ASSOCIATION FOR THE STUDY 

from the fluid in the duct and are found in moderate numbers in the sections 
situated in the caseous areas. 

Case V. — Male, white, set. 19, laborer, admitted to Pennsylvania Hospital 
March 8th, 1904. Patient is a well nourished young man; he has been sick 13 
days with abdominal pain and headache. No change in organs except enlarged 
spleen. 3-22 leucocytes 7,700; 4-4 some bloody expectoration, examination of 
chest negative. Leucocytes continually low; gradually worse, and death on 
June 7th. Temperature quite irregular throughout disease, remittent and vary- 
ing from below normal to 104°. Respirations about 28; pulse 100-120. 

Autopsy June loth, 1904, No. 577. 

Anatomical Diagnosis: Generalized subacute tuberculosis; tuberculosis of 
pleura and peritoneum; gelatinous pneumonia; tuberculosis of bronchial and 
retroperitoneal lymph nodes; tuberculous ulceration of intestines; tuberculosis 
of thoracic duct, cloudy swelling of liver and kidneys. 

Abstract of Autopsy Notes: The lungs show small and larger conglomerate 
tubercles together with areas of gelatinous consolidation. In the spleen, liver 
and kidney are scattered caseous tubercles varying from i mm. to i cm. in 
diameter. In the ileum there are several small shallow ulcers. The bronchial 
and mesenteric lymph nodes are very large and many are caseous or necrotic. 

Thoracic duct is distended with slightly milky fluid. When it is opened 
several small gray and yellow granules are seen upon the inner surface of its 
delicate walls. They are not numerous and are only seen at irregular intervals. 
Smears from the fluid in duct show a good number of tubercle bacilli. 

Case VI. — Male, white, set. 16, laborer. Admitted to Pennsylvania Hos- 
pital June 6th, 1904. Patient is a young, poorly nourished Italian boy. He has 
had a cough and has been spitting up blood for 2 months. Two days before 
admission he was exposed to cold and since then has had a bad headache and 
felt worse than before. The physical examination reveals a positive Kernig's 
sign but no other definite signs. On the 8th a complete left-sided palsy de- 
veloped. Patient gradually became unconscious and died on June 12th. 

Autopsy June 14th, 1904, No. 578. 

Anatomical Diagnosis: Generalized tuberculosis; tuberculosis of pleurae, 
pericardium and peritoneum ; tuberculosis and caseation of bronchial and medi- 
astinal lymph nodes; tuberculous ulceration of intestines; tuberculosis of cere- 
bral and spinal meninges and of ependyma ; tuberculosis of thoracic duct. 

Abstract of Autopsy Notes: The lungs are filled with small tubercles; 
there are no chronic changes. The spleen and liver show tubercles, sometimes 
caseous, varying from 1-3 mm, in diameter. The colon and ileum are the 
seats of moderate ulceration. 

Thoracic duct is delicate and contains but little fluid. On opening it 
several minute gray tubercles are scattered over its inner lining. 

Case VII. — Female, colored, aet. 20, admitted to Pennsylvania Hospital 
February 15th, 1905. Patient is a young colored girl, admitted with delirium 
and complaint of stiff neck. Her mother and one brother have tuberculosis. 
The patient is supposed to have had influenza. There is stiffness of neck and 
inequality of pupils while Kernig's sign is present. No lesion found in other 
organs. The patient gradually developed exopthalmos and became stuporous and 
died in coma on February 19th. Temperature was below 102°. Pulse 90-100; 
respirations 24. 



AND PREVENTION OF TUBERCULOSIS 1 89 

Autopsy February 19th, 1905, No. 665. 

Anatomical Diagnosis: Generalized acute miliary tuberculosis; tuberculosis 
of bronchial lymph glands with caseation ; tuberculosis of thoracic duct ; tuber- 
culous meningitis ; congestion of liver, spleen, kidneys and lungs. 

Abstract of Autopsy Notes: Minute tubercles are found scattered very 
thickly through the lungs, spleen, liver and kidneys. There are no chronic lesions 
discoverable in the lungs. There are no ulcers in the intestines. The bronchial 
lymph nodes are the seat of an old tuberculosis with caseation. 

Thoracic dust is dissected out to its entrance into the left subclavian vein. 
The portion which lies next to the vena azygos major is very much dilated, 
rather nodular in appearance, about the size of a leadpencil and bluish in color. 
Beneath the arch of the aorta the duct is narrowed, rather tough and thick. 
The duct is opened from the cephalic end. At the narrow portion there is a 
definite stricture through which it is difficult to pass the point of a small pair 
of scissors. This stricture lies a few centimetres below the entrance of the 
duct into the vein. The walls are thickened and the duct is narrowed by caseous 
material and fibrous tissue forming a mass the size of a pea. Above the 
stricture the duct is seeded with gray and yellow granules the size of a pinhead. 
The stricture measures i cm. in length and in its upper portion the lumen is 
only a few mm. in circumference. Below the stricture the wall of the duct is 
thickened and the lumen is dilated to a circumference of i cm. The wall is 
roughened and covered by minute gray and yellow points which give it a granular 
appearance. This condition extends down the duct for about 10 cm. The 
granules gradually disappear, giving way to a thick white wall. The duct is 
filled with bloody fluid and red blood clots. In the region of the stricture the 
bronchial lymph nodes are somewhat enlarged, firm and deeply pigmented. On 
section they show small caseous areas and streaks of dense white fibrous tissue. 
The largest measures about 2 cm. in diameter. There is no direct connection 
between the process in the lymph nodes and in the duct 

Case VIII. — Male, set. 47 years, admitted to Johns Hopkins Hospital, and 
died on July i8th, 1902. 

Autopsy July 19th, 1902, No. 1964. 

Anatomical Diagnosis: Primary tuberculosis of the epididymis and semi- 
nal vesicles; tuberculosis of the thoracic duct; acute miliary tuberculosis with 
miliary tubercles in lungs, liver and kidneys ; small cavities in lungs. 

Abstract of Autopsy Notes: The mesentery contains large, caseous 
lymph glands, the largest being about i cm. in lepgth. In the retroperitoneal 
tissue near the aorta there are a few enlarged lymph glands which become more 
numerous and larger above the diaphragm. 

Thoracic Duct: The thoracic duct is distended in its lower part and traced 
upward for about 12 cm., its wall becomes thickened and it has a nodular ap- 
pearance, and there are opaque yellow masses which can be seen shining 
through the lumen. About midway between the diaphragm and the aorta it 
receives a large branch which has a similar appearance. Above the level of 
the arch of the aorta the wall becomes soft and tubercles are not seen. 

Case IX. — Male, aet. 50, admitted to the Johns Hopkins Hospital. 

Anatomical Diagnosis: Acute miliary tuberculosis; tubercles in lungs, 
liver and kidneys; tuberculosis of thoracic duct; oedema of lungs; nodule in 
tonsil. Autopsy No. 1957. 



190 NATIONAL ASSOCIATION FOR THE STUDY 

Thoracic Duct: On exposing the thoracic duct immediately above the dia- 
phragm on the right side of the aorta it is found to be dilated to a diameter 
of about 3 mm. Traced inward at a point 7 mm. below the highest point of 
the arch of the aorta the duct is found to be occupied by an opaque yellow 
mass 4 mm. in diameter occupying the lumen and shining through the wall. 
Above this point the wall of the duct is considerably thickened and the duct 
itself is dilated to about 6 mm. in diameter. Traced upward it is found to 
bifurcate a short distance before it enters the subclavian and jugular veins. 
The duct is let open from the receptaculum to its termination. Evidently the 
lower thoracic part is entirely free but there are many lesions of the wall. The 
small nodule above mentioned is found to completely occlude the lumen and 
consists of solid caseous material. About 2 mm. below this point there are a 
number of minute opaque slight elevations. Similar discrete and confluent 
elevations above the nodule involve a considerable portion of the wall. In the 
upper part of the duct there is adherent to the surface a small amount of fi- 
brous material covered with blood. Immediately in contact with the duct, next 
to the caseous nodule occupying its lumen, is a large lymph gland 2.5 cm. in 
length, succulent and containing gray and opaque areas and in parts abundant 
coal pigment. The lymph glands on the right side along the carotic artery are 
very greatly enlarged and have a similar characteristic. Conspicuous is deep 
coal pigmentation. This gland forms a mass of considerable size. Beneath the 
arch of the aorta, at the bifurcation of the trachea, they form a large mass 3 cm. 
in diameter and black in color. 

Case X. — Male, aet. 43. Admitted to Johns Hopkins Hospital, 

Autopsy No. 1909. 

Anatomical Diagnosis: Tuberculosis; primary in epidiymes (?); ascend- 
ing genito-urinary infection ; extension into lymphatics ; infection of thoracic 
duct ; acute general miliary tuberculosis ; chronic left-sided pleurisy ; chronic 
diffuse pericarditis ; fatty degeneration of myocardium. 

The retroperitoneal lymph glands are enlarged, dry, and somewhat opaque. 
The mesenteric glands are also enlarged and contain definite caseous foci scat- 
tered over the cut surface; none are larger than a pinhead. 

Thoracic duct is found to be normal above the receptaculum chyli; within 
the latter situation it was almost occluded by a caseous mass the size of a bean. 
A few other caseous foci were also found. No other lesions were recognized. 

Case XL — Male, aet. 53, admitted to Johns Hopkins Hospital. 

Autopsy No. 1858. 

Anatomical Diagnosis: Acute miliary tuberculosis; tuberculosis of the 
mesenteric and retroperitoneal lymph glands; tuberculosis of thoracic duct; 
mihary tuberculosis of lungs, liver, and kidneys; cyst of left epididymis. 

The mesentery contains a large number of enlarged lymphatic glands, 
most numerous and largest at the base, where they frequently measure 2.5 cm. 
in length. On section of the smaller glands they are found to be firm, gray, and 
succulent; the larger glands are yellowish-gray and in places quite opaque. 
In the retroperitoneal tissue are found larger glands of similar character in 
great part opaque, yellowish on section ; they are very numerous, particularly 
near the hilum of the left kidney and near the pancreas. 

Thoracic duct is found above the diaphragm behind the root of the aorta, 
to the right of the median line; it passes upward behind the aorta toward the 
left. At a point midway between the diaphragm and the arch of the aorta it 



AND PREVENTION OF TUBERCULOSIS I9I 

becomes enlarged and its outline becomes irregular and at intervals can be seen 
groups of projecting nodules of a grayish, somewhat opaque color, usually 
about I mm. across. These become most numerous below the arch of the aorta, 
and here the duct is dilated to a diameter of about 6 mm. and its wall is con- 
siderably thickened, being from 0.5-1 mm. in thickness. The duct bridges the 
bifurcation of the jugular and subclavian veins and is here in contact with a 
large group of much enlarged lymph glands, the largest 2.5 cm. across, similar 
in character to those of the abdomen. 

Hardened Section — Thoracic Duct: The intima is beset with small 
raised elevations consisting of tissue which merges into the wall of the duct 
and involves the muscularis. This tissue consists of lymphoid and epithelioid 
cells. The superficial part of the nodule has in most instances undergone 
necrosis, stains homogeneously with eosin and contains nuclear fragments. 
The section passes through a valve, and the wall of the pocket formed by it 
shows most extensive changes. Here almost the entire thickness of the duct 
is invaded by new-formed tissue containing giant cells ; extensive caseation 
has occurred to the internal surface which is covered by a layer of fibrin. In 
the adventitia of the duct are numerous lymphoid cells. Stained for tubercle 
bacilli many were found; they are particularly numerous in the caseous ma- 
terial near the internal surface of the duct. 

Case XII. — Male, aet. 24, admitted to Johns Hopkins Hospital. 

Autopsy No. 256. 

Admitted to hospital September i8th, 1891 ; died December i, 1891 ; farm 
laborer. 

Complained of pain in side, shortness of breath, fever. Parents both died, 
probably of phthisis. Patient always healthy when young; frequently caught 
cold ; malaria two months ago, sharp attacks lasting two weeks. Five days 
ago had bad pain in side lasting twenty minutes ; breathing painful ; no chills ; 
no cough before. Had been exposed to wet. Bowels regular ; pain better ; 
coughing painful ; no alcoholic or venereal history ; no genito-urinary trouble ; 
urine — hyaline casts, faint diazo, no albumin, specific gravity 1020. 

Present Examination: Well nourished, mucous membrane good color, 
tongue whitish coat, slight general erythema all over trunk; face flushed, 
nervous look; temperature 102.6°, pulse 104, tension dicrotic. Resonance and 
respiration good in fronts, and left back ; below angle of right scapula and 
below 5th rib in right axilla dulness. Vocal fremitus diminished but present. 
Voice sounds somewhat nasal. Fine crepitus, not increased by cough. Heart 
— nothing remarkable. Abdomen — splenic dulness almost obliterated by tym- 
pany; not palpable. Liver — 6th (lower border) to costal margin: no tender- 
ness; no gurgling; no rose spots. 9-21. Urine, hyaline casts, no albumin, in- 
tense diazo. 9-22. Hypodermic needle inserted over dull area ; no fluid ob- 
tained ; general range of temperature lower ; patient seems bright ; no splenic 
enlargement; dulness in right back more marked; feeble respiration; no ab- 
dominal symptoms; temperature i03''-ioo°-i02°. 9-29. Two small papules (in 
addition to others noticed before) on back. 9-30 to lo-i. Temperature normal, 
rising again ; diazo-reaction reappears in urine after several days' absence ; 
urine negative; lungs clear. 10-8. Abdomen distended; patient dull. 10-13. 
Right lung (lower) shows about same signs as before. 10-25. Epididymis on left 
side swollen, hard and nodular. 11-16. Diazo-reaction again appears; had been 
absent for several days. 11-27. Average temperature for last fourteen days 
102° to 103°, very little expectoration. No tubercle bacilli found. Contrast 



192 NATIONAL ASSOCIATION FOR THE STUDY 

between bases of lungs as regards intensity of sounds ; in front below 4th rib 
on right side rales, tactile fremitus present. 11-28. Patient has been delirious; 
picks at bedclothes; pupils equal. 11-29. Pupils unequal; left, medium-sized, 
right moderately dilated; no evidence of hemiphlegia. 11-30. Blood-reds 
4.695,000. Urine — no albumin, no sugar, distinct diazo. White corpuscles 
10,000; haemoglobin 85%. 11-30 (8 p. m.). Pupils nearly equal; cornual reflex 
on left side sluggish ; left pupil a little more active than right. Left arm 
almost motionless; right arm moved voluntarily; left arm drops as if paralyzed; 
right leg resists flexion and extension; left leg drops loosely. Patellar reflex 
small on both sides, more marked on left. Face symmetrical. Patient un- 
conscious, sank and died in early hours of morning of December ist, 1891. 

Anatomical Diagnosis: Tuberculosis of left testicle and epididymus or 
chord, seminal vesicles and prostate; tuberculosis of abdominal glands and 
intestines (ulcers), and cerebral and spinal meninges; miliary tuberculosis of 
lungs, liver and kidneys; tuberculosis of thoracic duct; solitary tubercle of 
cerebellum. 

Abstract from Autopsy Notes: Lungs and heart removed in mass. Pos- 
terior mediastinal glands are enlarged and filled with caseous areas and miliary 
tubercles; in upper portion of mediastinum there is a lymphatic vessel size of 
2 mm. in diameter, which can be traced some distance. It occupies the posterior 
portion of the thoracic duct. In the course of this is a tuberculous mass which 
apparently is formed around the lumen of the vessel and on section a lumen 
can be demonstrated. Owing to the general adhesions it is not possible to say 
whether this be a small vein or the thoracic duct. Pleura over both lungs are 
enormously thickened; filled with a caseous material, along posterior edge of 
the right lung; just alongside of aorta, there is a distinct ridge-like projection 
which can be followed for some distance along lung and around its upper 
border. Both lungs on section contain numerous areas of miliary tubercles and 
there is here and there slightly peribronchial tuberculosis which in a few places 
has begun to break down. The bronchi in these places being dilated, their wall 
is caseous and the caseous material extends into the substance of the lungs. 

Case XIII. — Male, aet. 20, admitted to Johns Hopkins Hospital. 

Autopsy No. 1838. 

Anatomical Diagnosis: Acute miliary tuberculosis; tuberculosis of the 
mesenteric and retroperitoneal lymph glands; tuberculous peritonitis with ad- 
hesions; tuberculosis of the thoracic duct; miliary tuberculosis of the lungs, 
liver, spleen, kidneys, stomach, intestines, and cerebral pia mater; diffuse tu- 
berculous meningitis, limited to the spinal cord. 

Abstract of Autopsy Notes: The lymph glands in the retroperitoneal 
tissue in the neighborhood of the pancreas and on either side of the aorta are 
enlarged, often 1.5 to 2 cm. in length, firm, and grayish on section, and at 
times partially caseous. The largest consists of a number of glands matted 
together and is 3.5 mm. across, and situated at the hilum of the left kidney. 
The glands at the base of the mesentery are similarly enlarged. The lymphatic 
glands at the level of the bifurcation of the trachea and at the base of the neck 
are enlarged and contain gray, at times, opaque areas. 

Thoracic Duct: The thoracic duct where it lies to the right of the aorta 
just above the diaphragm is represented by an irregular nodular cord at one 
point where there is a deviation 0.5 cm. across; on section through this point 
cf maximum dilatation the lumen is found to be wholly obliterated, its wall 
indurated, and in the center is an opaque caseous substance. Below this point 



AND PREVENTION OF TUBERCULOSIS I93 

the duct dissected out is found to branch ; branches are conspicuous but are not 
dilated. Just behind and to the left of the aorta the duct is represented by a 
cord about 2 mm. in diameter. Its walls are thick, grayish-white in color and 
there occur nodules of the appearance of tubercles about i mm. across, seen 
somewhat indistinctly upon the surface. The orifice of the duct where it enters 
the external jugular vein is patent and admits a probe, passes from the inside 
duct into the vein. 

Case XIV. — Autopsy No. 1174: Dr. Flexner. 

Anatomical Diagnosis: Tuberculosis of lymphatic glands, generalized 
miliary tuberculosis (acute) with sero-fibrinous peritonitis and splenitis, chronic 
tuberculosis of peritoneal cavity as well as acute, acute splenic tumor, infarc- 
tion of spleen, tuberculosis of thoracic duct. 

Thoracic Duct: The thoracic duct is opened and what seem to be minute 
tubercles are seen beneath the serosa. 

Case XV. — Male, aet, 45, colored, admitted to Pennsylvania Hospital 
October 4th, 1903, in delirium. Clinical diagnosis, meningitis. 

Autopsy October 14th, 1903, No. 467. 

Anatomical Diagnosis: General acute miliary tuberculosis; chronic tu- 
berculosis and caseation of prostate and seminal vesicles ; thrombosis of left 
vesicular veins (tubercles in section); chronic apical pulmonary tuberculosis; 
tuberculosis of meninges; tuberculous ulcers of ileum; chronic tuberculosis of 
adrenals. 

Thoracic duct normal. 

Case XVI. — Male, set. 19, colored, admitted to Pennsylvania Hospital 
February 23d, 1903. Since August, 1902, for last 7 months, not feeling well; 
laid up 3 weeks ago. Death in 9 months. 

Autopsy No. 395. 

Anatomical Diagnosis: Subacute generalized tuberculosis; tuberculous 
broncho-pneumonia with cavity formation ; tuberculosis of left pleura and of 
bronchial lymph glands. 

Thoracic duct normal. 

Case XVII. — Male, set. 20, white, admitted to Pennsylvania Hospital 
April 27th, 1904; was in hospital from February 22d, 1904, to March 26th, 1904, 
with questionable pleural effusion. Worked until 3 days before admission. 
Death on August ist, 1904, with clinical diagnosis of tuberculous peritonitis. 

Autopsy August 2d, 1904, No. 594. 

Anatomical Diagnosis: Generalized tuberculosis with caseous nodules in 
lung, spleen, liver and kidney; caseation of lymphatic glands; tuberculosis of 
peritoneum. 

Thoracic duct normal. 

Case XVIII. — Female, white, aet. 13. Admitted to Pennsylvania Hos- 
pital March 15th, 1904. Laparotomy one year ago for tuberculous peritonitis. 
Admitted to hospital with this diagnosis for which a second operation was 
performed. Death April 13th, I904- 

Autopsy No. 547. 

Anatomical Diagnosis: Unhealed old laparotomy; tuberculosis of mesen- 
teric retroperitoneal and cervical lymph nodes; tuberculosis of peritoneum; 



194 NATIONAL ASSOCIATION FOR THE STUDY 

perforation of intestines; tuberculosis of spleen, intestines and lungs; fatty 
degeneration of liver; anaemia of all organs. 
Thoracic duct normal. 

Case XIX. — Male, white, aet. 40, admitted to Pennsylvania Hospital 
October loth, 1904; clinical diagnosis typhoid fever with meningitis. Death 
October 14th, 1904. 

Autopsy October 15th, 1904, No. 617. 

Anatomical Diagnosis: General acute miliary tuberculosis; chronic tuber- 
culosis of left apex ; tuberculous ulceration of intestines ; tuberculous meningitis ; 
generalized lymphatic tuberculosis. 

Thoracic duct a little thick; no definite tubercles. No tubercle bacilH in 
fluid from duct. 

Case XX. — Female, set. 53, admitted November 22d, 1904; sick three 
months with loss of weight; no definite signs detected in chest, some fever. 
Meningeal symptoms. Clinical diagnosis tuberculous meningitis. 

Autopsy December 4th, 1904, No. 631. 

Anatomical Diagnosis: General acute miliary tuberculosis; chronic pul- 
monary tuberculosis with cavity formation; tuberculosis of uterus; tubercu- 
lous peritonitis; rupture of intestines with acute fibrino-purulent peritonitis; 
tuberculous ulceration of intestines. 

Thoracic duct normal. 

Case XXI. — Male, set. 19, white, admitted October 25th, 1904, to the 
Pennsylvania Hospital. Malaise for ten days ; thought at first to "be typhoid, 
later tuberculous peritonitis; operation November 19th; fecal fistula. Death 
January loth, 1905. 

Autopsy January loth, 1905, No. 645. 

Anatomical Diagnosis: Generalized tuberculosis, subacute; tubercles con- 
glomerate and fairly large in spleen and liver; chronic pulmonary tuberculosis; 
tuberculous peritonitis ; laparotomy. 

Thoracic duct normal. Smears show no tubercle bacilli. 

Case XXII. — Male, set. 21, colored, admitted to Pennsylvania Hospital 
February 8th, 1905; sick 7 days; operation for appendicitis. Death February 
21 St, 1905. 

Autopsy No. 668. 

Anatomical Diagnosis: Chronic tuberculosis of lungs with cavity forma- 
tion; tuberculosis of peritoneum with acute purulent peritonitis; extensive tu- 
berculous ulceration of intestines; appendectomy; tuberculosis of mesenteric 
lymph nodes ; cloudy swelling of liver and kidneys. 

Thoracic duct dissected out into entrance into subclavian vein. It is nor- 
mal. No smears from duct. 

Case XXIII. — Female, white, set. 13, admitted to Pennsylvania Hospital 
February i6th, 1905; sick since December loth, 1904, symptoms of meningitis; 
fever while in hospital. Death February 25th, 1905. 

Autopsy February 26th, 1905, No. 671. 

Anatomical Diagnosis: Generalized tuberculosis, subacute; chronic tuber- 
culosis of bronchial lymph nodes; partial consolidation of right lung; bron- 



AND PREVENTION OF TUBERCULOSIS I95 

chiectatic cavities in left lung; localized tuberculous peritonitis; tuberculous 
meningitis ; tuberculous ulceration of intestines. 
Thoracic duct normal. 

Case XXIV. — Male, aet. 66, admitted to Pennsylvania Hospital Augfust 
7th, 1904 ; sick for 4 months ; clinical diagnosis of tuberculosis of lungs. 

Autopsy August 31st, 1904, No. 600. 

Anatomical Diagnosis: General acute military tuberculosis; acute tubercu- 
losis of pleurae and peritoneum; chronic tuberculosis of mesenteric lymph nodes 
and of left lung; cloudy swelling of liver; acute splenic tumor; chronic diffuse 
nephritis. 

Mesenteric lymph glands size of man's fist, caseous. Thoracic duct normal ; 
no tubercle bacilli found in smears from fluid. 

Of these 25 cases 17 were typical instances of generalized acute 
miliary tuberculosis, where minute tubercles were scattered in enor- 
mous numbers through most of the organs of the body. When histories 
could be obtained the course of the disease was rapid, lasting usually 
from two to twelve weeks. The thoracic duct in 12 of the 17 cases 
showed a more or less extensive tuberculosis usually with caseous 
nodules, while in one instance, though there was no tuberculosis of the 
walls of the vessels, many tubercle bacilli were found in smears from 
the duct lymph. In one of the 4 remaining cases in which the duct was 
normal there was a primary tuberculosis of one epididymis and testicle 
with organized thrombi in the vesical veins, containing caseous masses 
and tubercles. 

In 6 instances the generalized process was subacute or chronic. 
Large tubercles or caseous masses were scattered in small numbers 
through the various organs while during life the course of the disease 
was protracted, lasting from three to nine months. In only two of these 
cases was there a tuberculosis of the thoracic duct. In both instances 
the tubercles were small and occurred sparingly, but in one a few 
tubercle bacilli were found in smears from the fluid of the duct. 

Finally, in two instances the tuberculosis was of a chronic type and 
confined to the lungs and peritoneum. In both of these cases the tho- 
racic duct was normal. 

It is difficult to draw a line between the cases of acute and sub- 
acute generalized tuberculosis, but between the extremes of the two 
types a distinction can certainly be made. The cases with which we 
had to deal were fortunately distinctive. Of the 23 cases of generalized 
tuberculosis 15, or over 65%, showed tuberculosis of the thoracic duct, 
or, as in one instance, tubercle bacilli in the lymph from the duct with- 



196 NATIONAL ASSOCIATION FOR THE STUDY 

out lesions of its walls ; while of the acute cases in over 76% the duct 
was affected. 

The type of lesion in the duct varied considerably. Sometimes 
there was a single large caseous nodule usually near the receptaculum or 
about the arch of the aorta with small tubercles over the intima of the 
vessel above and below it; sometimes several caseous nodules were 
scattered through the duct, while, occasionally the walls of the lym- 
phatic were simply seeded with small tubercles. In every instance the 
lymph nodes of the mesentery, retroperitoneum, posterior mediastinum 
or bronchial regions were the seat of a chronic tuberculosis. At times 
several groups of glands were affected, but more often only one group, 
and rarely only one or two glands, as in Case VII. 

Often the lesion in the duct appeared almost as old as that in the 
neighboring lymph nodes and was in close association with it, though a 
direct extension of the process from the gland to the wall of the duct 
was never seen. In at least two instances the caseation of a small 
group of lymph nodes and of the thoracic duct wall were the only foci 
of chronic disease which could be found in the body. 

This intimate association between the lesions of the lymph nodes 
and of the duct which existed so often leads one to suppose that the 
infection travels directly from the lymph nodes through the lymphatic 
to the thoracic duct. It is well known, through the experiments of 
Nicolas and Descos,^ Arloing,^^ Ravenel' and others, that tubercle bacilli 
when fed to dogs may pass directly through the intestinal wall without 
producing perceptible lesions, travel to the mesenteric lymph nodes and 
rapidly enter the thoracic duct where they may be demonstrated soon 
after the feeding. The method of infection ascending from foci of dis- 
ease in the abdomen or traveling from lymph nodes elsewhere in the 
body through the blood to the lungs has recently received much study. 
Harbitz* has lately reviewed the Hterature upon this subject. 

Apparently the same series of events takes place in these cases of 
thoracic duct infection. In a certain number of instances tubercle 
bacilli are carried to the thoracic duct from adjacent tuberculous lymph 
nodes. Here they lodge and produce a localized subacute or chronic 
lesion. Sooner or later this nodule breaks down and enormous numbers 
of tubercle bacilli, as may be demonstrated by smears of the lymph, are 

' Centr. f. Back. u. Parasit., 1902, Bd. XXXII, p. 306. 
' Presse Med., 1903, Tome I, No. 29, p. 298. 
'Jour, of Med. Research, 1903, Vol. X, p. 460. 
* Jour, of Infect. Diseases, 1905, Vol. II, p. 



AND PREVENTION OF TUBERCULOSIS 1 97 

liberated and swept by the lymph into the general circulation, producing 
an acute and rapidly fatal general tuberculosis. Even if a large tribu- 
tary to the duct is the seat of a caseous tuberculosis the same series of 
events may follow, and, as in one of our series of cases, tubercle bacilli 
would be swept into the lymph of the duct without of necessity pro- 
ducing changes in its walls, or as has been frequently noted, only giving 
rise to a miliary tuberculosis of the duct itself. It has frequently been 
shown that neither during life nor at autopsy can large numbers of 
tubercle bacilli be demonstrated in smears from the blood, so that the 
mere presence of large numbers of tubercle bacilli in the lymph from 
the thoracic duct suggests that they are disseminated from a reservoir 
near by. 

Of special interest are the cases of subacute generalized tuber- 
culosis with lesions in the duct. In such cases it seems probable that 
from tuberculous lymph nodes, tributaries to the duct, and small foci 
of tuberculosis in the duct itself, a few tubercle bacilli may from time 
to time be swept by the lymph into the circulation and scattered to dif- 
ferent parts of the body, producing a chronic general infection instead 
of the rapidly overwhelming type of infection. 

Our series of cases suggest therefore that the thoracic duct is of 
great importance as a channel for the spread of tubercle bacilli through 
the body from the various groups of lymph nodes. Undoubtedly, tuber- 
culosis of the veins and arteries is also to be reckoned as a factor in the 
rapid dissemination of tubercle bacilli through the body, but is sub- 
sidiary in importance to tuberculosis of the thoracic duct and its tribu- 
taries. 

From a study of these cases the following conclusions may be 
drawn : — 

Tuberculosis of the thoracic duct is of great frequency in cases of 
acute generalized tuberculosis. The lesions in the duct from which 
tubercle bacilli are swept in great numbers through the lymph to the 
general circulation form the starting-point for the generalized acute 
process. In certain cases of acute generalized tuberculosis, tubercle 
bacilli may be found in the lymph from the duct, though the duct itself 
is not the seat of tuberculosis. In a small percentage of cases of sub- 
acute generalized tuberculosis the duct may also be affected. 



VICARIOUS ACTION OF THE BOWELS FOR THE 
KIDNEYS IN TUBERCULOSIS 

By Lawrence F. Flick, M. D., and Joseph Walsh, M. D. 

Philadelphia 



It has long since been recognized that in certain cases of tuber- 
culosis there is a looseness of the bowels which is not due to ulceration. 
This looseness has been termed in the text-books an irritative diarrhea 
and has been ascribed to errors in diet. Where it has occurred in cases 
which have come to autopsy the bowels have been found free from 
ulceration and apparently in a healthy condition. 

A careful study of a number of cases which have been under obser- 
vation for a long time clinically, and which have come to autopsy, has 
led us to believe that in these cases the looseness of the bowels is due to 
a vicarious action of the bowels for the kidneys and that nature is really 
trying to protect the system by this vicarious action. 

Though the diagnosis " enteritis " from the clinical symptom diar- 
rhea is frequently allowed to stand even when the autopsy findings are 
negative, it is to be remembered that the more we study pathology the 
fewer clinical symptoms do we attribute to apparently healthy organs. 
We can understand how a diarrhea of a few days' standing produced by 
an acute enteritis might be undiscoverable at autopsy, but we do not 
believe that a diarrhea of weeks', months', and even years' duration can 
properly be attributed to what at autopsy seems to be a normal intestine. 

We have eleven (ii) cases to report. In all of them there was 
severe diarrhea, usually over a protracted time. In all the intestines 
were found normal, and the kidneys were found to have undergone 
acute alterations. 

Two of the cases were private patients and nine were patients of 
the Phipps Institute. In one of the private cases the autopsy was made 
by C. Y. White and in the other by Joseph Walsh. The autopsies on 
the cases in the Phipps Institute were made by R. C. Rosenberger. 

198 



NAT. ASS'N for study AND PREV. OF TUBERCULOSIS 1 99 

The microscopic study in one case was made by C. Y. White and in the 
other ten by Joseph Walsh. The study of the kidneys was macroscopic 
and microscopic. The kidneys in nine cases out of the eleven were cut 
into one hundred and forty to one hundred and fifty small pieces and 
each piece was examined macroscopically. A varying number of pieces 
were then blocked and microscopic sections made. From twelve to 
sixty microscopic specimens were studied in each case.^ 
The cases were as follows : — 

Case No. i. — (Private patient — Flick.) Female, single, schoolteacher, 
age 31 years. She came under treatment first on the 23rd of June, 1901. Her 
history of exposure to tuberculosis dated twelve (12) years back. She gave a 
history of having had severe colds for several years. She weighed 113 lbs. and was 
in an acute stage of the disease. She had tubercle bacilli in the sputum and 
had signs of involvement of both lungs. She improved rapidly under treatment 
and in about 11 months was able to go back to teaching. She weighed 150 lbs. 
at the end of the first year's treatment and her pulse and temperature were 
normal. While teaching she again lost weight ; dropping down to 145 lbs. She 
regained her weight during the summer vacation and went back to teaching 
in the fall. During the early winter months she lost weight but remained pretty 
well. She again regained her weight and by spring weighed 150 lbs. During 
the spring months she again lost slightly and at the end of her second year's 
treatment she weighed 143 lbs. and was in a pretty fair condition of health in 
spite of the fact that she had taught one year. She went to the mountains for 
her summer holiday and returned in October in rather bad condition. She had 
lost II lbs. and showed congestion of considerable of the left lung and the 
upper part of the right lung. She now had a pulse of 120 and had to gxJ 
to bed for a while. She again gained in weight and improved in every way 
so that by December she weighed 1395^ lbs. She was very short of breath, 
however, upon exertion and suffered alternately from constipation and diarrhea. 
From this time on she had alternate periods of diarrhea and constipation 
although occasionally her bowels were in good condition. In April, 1904, a 
cavity formed in the upper part of the left lung after which she again im- 
proved in many ways although she did not gain in weight. She weighed at 
this time 136 lbs. Her pulse became more rapid and her dyspnoea increased. 
In June her pulse ran as high as 130. In August she weighed 130 lbs. and her 
pulse was 124 although she felt pretty well. In tlie latter part of August she 
was taken quite ill with great looseness of bowels and extreme weakness. The 
physician who was called diagnosed her case as severe diarrhea and treated 
her for it with bismuth and opium. She unexpectedly died on the third day 
of her illness. There is no record of an examination of urine in this case 
although nephritis was suspected for some time and our recollection is that 
an examination of urine was made but found negative. Our recollection also 
is that there was edema of the legs. 

Autopsy (Walsh), August 24, 1904, 8.30 P.M. Autopsy done in private 
house. 

Pathological Diagnosis: Bilateral chronic adhesive pleurisy; healed tuber- 

* We wish to thank Mr. Karl W. Smith whose assistance made this detailed 
study of the kidneys possible. 



200 NATIONAL ASSOCIATION FOR THE STUDY 

culosis of the right lung; partially healed tuberculosis of the left lung with 
cavity formation ; emphysema and edema of both lungs ; tuberculosis of the 
bronchial glands; acute diffuse nephritis; a few scattered tubercles in the 
kidneys. 

External Appearance: Well nourished female; no decomposition; post- 
mortem rigidity quite well marked; no post-mortem lividity; no jaundice; edema 
of both feet. Subcutaneous fat well developed and preserved; ^ of an inch 
over the thorax, one inch over the abdomen and about 3^ inch in the omentum. 
Abdominal and thoracic muscles apparently normal. Position of abdominal, 
pelvic, and thoracic viscera normal. Peritoneum : Normal. 

Pleura: Left — Dense adhesion over the upper lobe and especially over 
the apex. In breaking up these adhesions in the apex a cavity in the lung was 
opened. Scattered and easily broken adhesions over the lower lobe. Right — 
Dense adhesion over the upper lobe though not so dense as on the left side. 
There was practically no exudate. 

Lungs : Left — Large, emphysematous and edematous. Pale in color. The 
apex of the upper lobe presented a cavity, 2 by 3 inches in diameter. The 
cavity had smooth walls and was empty. There was slight infiltration about it. 
Except for the edema and emphysema the rest of the lung was normal. Right 
— The lung was generally emphysematous and edematous. There were several 
scars evident over the apex. No infiltration. Pericardium : Normal ; no ad- 
hesions and a normal amount of fluid. Bronchial Glands: Enlarged but not 
caseous. 

Heart: Completely covered by emphysematous lungs; normal in size, 
color and consistency; sub-epicardial adipose tissue marked. Valves — Normal. 
Aorta : Normal. Spleen : Slightly enlarged and congested ; shape and consis- 
tency normal. Liver: Size, consistency and color normal. Gail-Bladder: 
Normal. Suprarenal : Left — Apparently normal ; Right — Not examined. 

Appendix: Normal; no tuberculous ulceration apparent. Stomach: 
Normal in position ; mucous membrane of pink tint. Small and large Intestines 
and Rectum: Normal; no blood; no appearance of inflammation; no ulcers. 
Ovaries and Uterus : Apparently normal. Mesenteric Glands : Normal ; not 
enlarged. 

Kidneys : Left — Enlarged once and one half to twice normal size ; shape 
normal ; capsule slightly adherent ; consistency softer than normal ; surface of 
section cloudy, dull ; cortex markedly thickened, pale in color ; pyramids normal 
in size but congested. Several small, yellowish, milletseed to split-pea-size areas 
on external surface and surface of section. Right — Exactly similar to left. 
Both kidneys cut into 140 small pieces. 

Microscopically: (Walsh) 40 specimens examined. Kidney investment 
normal. Malpighian bodies normal distance from kidney surface. Glomeruli 
enlarged. Hyaline degeneration apparent in the epithelial cells of the loops. 
Quite marked thickening of the connective tissue of Bowman's capsule. Wide- 
spread marked necrosis of the epithelium of the convoluted tubules and of the 
secreting tubules of the medullary rays. Numerous hyaline casts. Thickening 
of the interstitial tissue between the tubules. Infiltration of small round cells 
between tubules, and sometimes about glomeruli. Several areas of destroyed 
tubules replaced by infiltration of small round cells which look like young 
tubercles. Blood-vessel walls thickened. Several typical tubercles with casea- 
tion and giant cells. Diagnosis : Acute diffuse nephritis. 



AND PREVENTION OF TUBERCULOSIS 201 

Case No. 2. — (Private patient — Flick.) Male, age 18 years, 6 ft. 2 in. 
in height, student. He was exposed to tuberculosis for a considerable period 
of time when six years of age. He was again exposed for a considerable period 
of time when 13 years of age. He was a fairly healthy child, but was always 
thin. The highest weight that he had ever reached was 145 lbs. about one year 
before death. He broke down in health after a very severe year of study and 
overwork in college one year before death. In spite of rest the disease re- 
mained active during the year. He first came under observation (Flick) two 
months before death when he was extremely weak, unable to move about and 
ran a pulse of 122 at rest. He had had loose bowels for four months at this 
time. Physical examination revealed a cavity in the upper lobe of the right 
lung with more or less infiltration of the entire lung and extensive involve- 
ment of the upper half of the left lung. He had considerable tenderness over 
the abdomen and gave some evidence of appendicitis. In spite of all that 
could be done the disease ran to a fatal termination in two months. 

Autopsy and Pathological Report (C. Y. White). 

Pathological Diagnosis: Chronic tuberculosis of the lungs with cavity 
formation ; miliary tuberculosis of the lungs, liver, spleen, and kidneys ; 
subacute parenchymatous nephritis ; chronic fibroid pleurisy ; acute splenitis. 

External Appearance — The body of an emaciated young man about twenty 
years of age. The subcutaneous tissue contains a small amount of fat. The 
external lymphatic glands are not enlarged. Post-mortem rigidity is marked. 
Post-mortem lividity in the dependent parts of the body. The body had been 
injected with preserving fluid before the autopsy. 

Abdomen — The peritoneal cavity contains about one litre of bloody fluid 
— part of which is injection fluid. There is one small puncture wound in the 
epigastrium presumably from the injection instrument. The organs are all dis- 
colored — varying from a bleached pale pink to a deep red. 

Intestines — The intestinal coils are moderately distended with gas. The 
walls are irregularly congested. Section over these areas does not show ulcera- 
tion. The large intestine is simular to the small but not so deeply congested. 
Appendix — The appendix is bound down with firm adhesions. The walls are 
moderately thickened and congested. Section shows the walls thickened and the 
lumen small. Microscopical examination shows the wall congested and the 
muscular coats infiltrated with round cells. — Subacute appendicitis. 

Liver — The liver is moderately enlarged, firm and of a yellow color. The 
surface is mottled and bleached from the injection fluid. Section shows the 
cells pale and the organ congested. Throughout th,e section surface and on the 
surface of the organ there are numerous small 2 mm. yellowish tubercles. 
Microscopical examination of the organ shows the liver cells cloudy and the 
organ congested. Numerous early and some moderately advanced miliary 
tubercles are to be seen throughout the section. 

Spleen — The spleen is enlarged, soft and of a deep red color. The 
lower surface and edge of the organ are bleached from the action of the in- 
jection fluid. Section of the organ shows the organ congested and the trabec- 
ulae not increased. No distinct miliary tubercles are to be seen on the section 
surface. Microscopically the organ is congested and the section shows a few 
small miliary tubercles. These tubercles show a slight caseous centre and a 
few giant cells. 

Kidneys — The kidneys are both enlarged, soft and of a pale color. The 
capsule strips easily showing a pale somewhat yellowish cortex. Section of the 



202 NATIONAL ASSOCIATION FOR THE STUDY 

organs show the cortex greatly thickened and yellowish pink in color. The 
medulla is deep red. The surface and section surface of the organs show a few 
scattered miliary tubercles. Microscopical examination shows the sections of 
the kidneys to be moderately congested. The epithelium of the tubules of the 
cortex is swollen and cloudy and in some places distinctly granular. The 
lumen of the tubules is in places partly filled with granular debris. The cells 
in places are slightly necrotic. The cross-section of the tubules of the me- 
dulla show in places the lumen to contain granular material. 

Heart — The heart is somewhat dilated and filled with currant-jelly clots. 
The muscle is yellowish red and somewhat soft. The valves are apparently 
normal. 

Lungs — Both pleural cavities are filled with bloody fluid. There are a 
few firm adhesions in both cavities. Right lung: The upper and part of the 
middle lobes contain a large cavity which is situated along the anterior surface 
of the lungs and varies from one to two cm. below the surface. The greater 
part of this cavity is within the upper lobe. Almost all of the remaining upper 
lobe is consolidated. This consoHdation. varies in color from a deep red to a 
caseous yellow. The greater part is caseous, i. e., small caseous areas separated 
by deeply congested and infiltrated lung tissue. The lower lobe contains num- 
erous one to two mm. yellowish tubercles and a moderate amount of edema. 
Left lung: The upper part of the left upper lobe is consolidated and contains 
a small cavity measuring about two to three cm. in diameter. The cavity is 
situated in the posterior-lateral part of the lobe. The lower part of the lobe 
and the whole of the lower lobe contains numerous small two to three mm. 
caseous tubercles, a moderate amount of congestion and a slight amount of 
edema. 

Case No. 3. — Phipps Institute Case. (Hatfield, Brinton and Walsh.) 
Abstract. 

No. 236, Vol. II. Male, age 32. Occupation — Laborer. Entered hospital 
4-21-03. Duration of illness — 8 years. First symptom — Pneumonia. No 
edema. Sputum — T. b. positive. He was discharged from hospital 4-21-04. 
He re-entered Sept. i, 1904; died October i, 1904. 

Bowels — From 4-21-03 to Feb. i, '04, according to temperature chart, 
generally constipated. Patient's statement 4-22-03 constipated; 4-24-03 con- 
stipated; 10-3-03 constipated; Feb. 5, '04 constipated; August 23, '04 diarrhea; 
from Sept. i, '04 to Oct. i, 04 bowels somewhat loose; as follows: 6, 5, 2, 2, 2, 
I, I, 2, I, 2, o, 2, 2, I, 2, 2, 2, 2, 2, I, 2, 2, 2, 2, 6, 4, 4, 3, death. 

Urine — 7-14-03 trace of albumin, no sugar, many pus cells, no casts. 
7-18-03 no albumin. 10-28-03 urethral discharge like gleet. 4-22-04 albumin 
present, no sugar, granular casts. 6-1-04 no sugar, albumin and blood present, 
much debris. March 8, '04 acid, 1032, albumin present, no sugar, no diazo. 
Sept. 3, '04, cloudy white precipitate, no sugar, hyaline and granular casts, pus 
in great quantities, epithelial cells, debris. T. b. positive. 9-15-04 pain in blad- 
der and incontinence. 6-18-03 considerable pain in right lumbar region. 
7-13-03 pain in left lumbar region extending down to left groin. Three or 
four months previous to death the diagnosis of tuberculosis of the left kidney 
(that is surgical kidney) was made. 

Heart — 4-22-04 accentuated second sound. Pulse: During first year in 
hospital pulse was between 90 and 100; respiration between 25 and 30; temper- 
ature between 98 and :oo. During last two weeks of illness pulse, temperature 
and respiration gradually became elevated. 



AND PREVENTION OF TUBERCULOSIS 2O3 

Autopsy (Rosenberger). Abstract. 

Pathological Diagnosis: Fibroid tuberculosis of right lung; ulcerative 
tuberculosis of both lungs; chronic parenchymatous nephritis right kidney; 
ulcerative tuberculosis of left kidney; cystitis; amyloid spleen; congestion of 
liver and calcified tubercle. 

Heart — Normal. Aorta — Beginning atheroma. Spleen — Amyloid- 
Liver — No amyloid reaction obtained, i calcified tubercle, otherwise normal. 
Bladder — Tuberculous ulceration. Suprarenal — Tuberculosis of left supra- 
renal. 

Intestines — Normal. Appendix — Small, no ulcers. Mesenteric Glands 

— Not enlarged. 

Kidneys — Left, 7 oz. ; enlarged and swollen, shows three large ulcerated 
areas averaging 3 cm. in diameter, each surrounded with fibrous tissue. Right 

— Enlarged, swollen, pale. (Walsh.) Right cut into 70 small sections. Nothing 
further found except a very small cyst. 

Microscopically : 38 sections studied. Glomeruli swollen, sometimes 
fibroid; epithelium sometimes shows a vacuolated condition (hyaline vacuolar). 
Bowman's capsule thickened. Convoluted tubules — Widespread degeneration 
and necrosis of the epithelium. Innumerable hyaline casts ; many cellular and 
granular casts. Round cell infiltration between tubules. Tubules sometimes 
contain red blood cells, again white blood cells. Secreting tubules of medullary 
rays swollen and necrotic. Interstitial connective tissue thickened. General 
congestion especially of pyramids. No amyloid to Gentian violet. No tubercles 
found. Diagnosis: Right — Marked diffuse nephritis; left — Advanced tuber- 
culosis. 

Case No. 4. — Phipps Institute Case. (Hatfield.) Abstract. 

No. 1032, Vol. 12. Male, age 27, single. Occupation — Coppersmith. En- 
tered hospital 6-30-03. Duration of illness — i year. Edema present but his- 
tory does not say where. Heart — 6-30-03 dullness increased up and to right; 
second pulmonic accentuated. Pulse — 100 to 120; respirations 26 to 32; temper- 
ature 97 to 100. He left hospital of his own accord Aug. 12, '03 ; he re-entered 
without being seen in the meantime, 8-9-04 and died 9-10-04. Clinical diag- 
nosis — Tuberculosis of the lungs and pleura; tuberculosis of the intestines. 
Principal Symptoms during second stay in hospital — Cough, expectoration and 
looseness of bowels. 

Bowels — 6-30-03 fairly regular; while in house from 6-30-03 to 8-12-03 
bowels were alternately constipated and slightly loose. On entering hospital 
8-9-04 he complained of diarrhea. From the time of. entrance to hospital, 8-9-04, 
till death his stools averaged about four a day though once 12. 

Urine — 7-10-03 no albumin, no sugar, no casts. 

Autopsy (Rosenberger). Abstract. 

Pathological Diagnosis: Ulcerative tuberculosis of both lungs with em- 
physema ; tuberculous pleurisy ; fatty kidneys ; amyloid spleen ; congested liver. 

Heart — 7^ oz. ; normal. Spleen — 7 oz. ; enlarged ; consistency dimin- 
ished ; dark red ; reacted to the iodine stain. Liver — 2 lbs. 6 oz., small, con- 
gested ; mottled in appearance. 

Intestines — Normal. Appendix — Tubercles. Mesenteric Glands — Not 
enlarged. 

Kidneys: Left — 6 oz. ; slightly larger than normal; pale; tubercles evident. 
Right — 5 oz. ; same as left. (Walsh.) Both kidneys cut into 140 to 150 sec- 
tions. Left showed two small tubercles. 



204 NATIONAL ASSOCIATION FOR THE STUDY 

Microscopically: 24 specimens studied. Widespread degeneration and 
necrosis of epithelium of convoluted tubules. Occasional slight round cell in- 
filtration between tubules, between the epithelial cells in convoluted tubules and 
into the tubules. Connective tissue of Bowman's capsule thickened. A few 
hyaline casts. No amyloid to Gentian violet. Typical tubercles with caseation 
and giant cells. Diagnosis : Parenchymatous nephritis ; scattered tubercles. 

Case No. 5. — Phipps Institute Case. (Stanton.) Abstract. 

No. 1 157, Vol. 13. Female, age 34, widow. Occupation — Domestic. En- 
tered hospital 7-29-03; died 6-3-04. Diagnosis — Tuberculosis of the lungs, 
larynx, and glands of neck and axilla. Duration of illness — 6 months. No 
edema. Sputum — T. b. positive. Heart — Normal. Pulse — 80 to 90; respira- 
tions 20 to 30; temperature 98 to 100. Towards the end all three elevated. 

Bowels — 7-29-03 patient said bowels regular; during Aug. '03 average i 
to 2; during Sept. '03 average 2; during Oct. '03 varied from o to 3; during 
Nov. '03 average i; during Jan. '04 i or o; in other words a little tendency to 
constipation alternating occasionally with looseness; 3-6-04 diarrhea; 3-11-04 
diarrhea severe; 3-16-04 diarrhea better; 3-25-04 diarrhea, blood in stools; in 
other words from Feb. ist to March 6th, '04 pretty regular, generally only one, 
once 2, again 3; March 6th 9 stools; March 6th to March nth. 9, 4, 5, 4, 5, 4; 
then regular, i or at most 2 a day till April ist. 4-1-04 3; 4-2-04 4; 4-18-04 3 
and after that 3 and 4 a day till death. 

Urine — 7-29-03 acid, loio, no albumin, no sugar. Microscopically: Leu- 
cocytes. 

Autopsy (Rosenberger.) Abstract. 

Pathological Diagnosis: Miliary tuberculosis of both lungs with cavity in 
both; emphysema; congestion; kidney infarct; catarrhal appendicitis; red 
atrophy of liver ; extreme emaciation. 

Heart — 8^ oz. ; right ventricle shows fatty infiltration, the ventricle wall 
is thin, about 3 mm. ; muscle flabby, otherwise normal. 

Spleen — 35^ oz. ; small and firm. Liver — 2 lbs. 14 oz. ; dark red, presents 
the appearance of red atrophy. 

Intestines — Normal. Appendix — Normal. Mesenteric Glands — En- 
larged, not caseous. 

Kidneys : Left — 4^ oz. ; recent congestion ; old infarct ; pale. Right — 
4J^ oz. ; same as left except infarct 

Microscopically: (Walsh.) 10 sections studied microscopically. Glome- 
ruli swollen, epithelium vacuolated ; no congestion. Convoluted tubules : 
Epithelium swollen, degenerated and occasionally necrotic; same is true of the 
secreting epithelium of the medullary rays. Slight thickening of interstitial 
tissue. No congestion. No appearance of amyloid. Not stained for amyloid. 
Infarct not studied. Typical tubercles with caseation and giant cells and tu- 
bercle bacilli. Diagnosis : Toxic nephritis ; scattered tubercles. 

Case No. 6. — Phipps Institute Case. Abstract. 

No. 2180, Vol. 16. Female, age 42, married. First visit 3-11-04; entered 
hospital 3-31-04; discharged 5-12-04; re-admitted 7-16-04; died 10-27-04. Dura- 
tion of illness — 2 years. No edema. Sputum — T. b. present. Heart — 
Sounds poor in quality, systolic murmur at pulmonary area; 7-27-04 second 
pulmonic accentuated, systolic murmur nt pulmonic area also at apex; mitral 
murmur probably hemic; dyspnoea extreme. Pulse: During first stay in hos- 
pital 90 to no; respirations 30; temperature 98 to 100; after re-admission to 



AND PREVENTION OF TUBERCULOSIS 20$ 

hospital pulse no; respiration 32; temperature 98 to 102. During Sept. respira- 
tions oftentimes went up to between 40 and 50. 

Bowels — 3-1 1-04 regular; on admission 3-31-04 she said regular; 7-19-04 
very loose; 7-27-04 condition of bowels much improved; from 4-1-04 to 4-30-04 
during stay in hospital bowels quite regular, usually one, once o, ten times 2; 
from time of re-admission, 7-16-04, till death there were frequent spells of 
looseness; 7-22, 5; 7-28, 7; 8-3, 7; 8-4, S; 8-10, 5; 8-14, 5; 8-21, 5; 9-19. 5; 9-27.6; 
9-28, 6; 9-29, 6; 9-30, 5; 10-9, 5; 10-10, 6; lo-ii, 4; 10-12, 5; 10-14, 10; from this 
time till death 4, 4, 5, 4, 7, 5, 5, 6, 4, 3, 6, 4, 8. In addition during July, Aug. 
and Oct. there were practically never less than 3 or 4 a day. 

Urine — 3-20-04 amber, acid, 1024, trace of albumin, no sugar, no casts; 
7-19-04 acid, yellow, albumin positive, no sugar, diazo positive. 

Autopsy (Rosenberger). Abstract 

Pathological Diagnosis: Pleurisy of both sides; tuberculosis of both 
lungs ; caseous pneumonia of right lung ; congestion of liver ; mitral valvulitis ; 
parenchymatous nephritis; atheroma of the aorta and splenic artery; capsulitis 
of spleen and liver; appendicitis. 

Heart — Displaced to left ; mitral valve markedly thickened ; fenestration 
of the middle aorta leaflet ; chordae tendinae of mitral valve also thickened ; 8 oz. 
Spleen — 6 oz. ; slightly enlarged; rather firm; area of capsulitis posteriorly; 
pinpoint areas resembling tubercles; splenic artery atheromatous. Liver — 
Slightly enlarged ; 2 lbs. 14 oz. ; veins slightly dilated ; more or less mottled on 
section. 

Intestines — Ileum much congested ; no ulcers present ; rest of intestines 
normal. Appendix — 6 cm. in length; swollen near tip; connects with another 
mass on left, upon opening this mass purulent material was found and perfora- 
tion near the tip. Mesenteric Glands — Enlarged; some calcified. 

Kidneys : Left — 5 oz. ; slightly enlarged ; shows slight congestion ; two 
small areas apparently tubercles. Right — 4 oz. ; paler than left ; firm in con- 
sistency; evident macroscopical tubercles. (Walsh.) Both kidneys cut into 
140 to 150 sections. 3 small tubercles found. 

Microscopically — 13 specimens studied. Glomeruli sometimes swollen. 
Rare fibroid glomerulus. Connective tissue of Bowman's capsule thickened. 
Necrosis of epithelium of convoluted tubules ; lumina frequently filled with 
debris. No round cell infiltration. Few hyaline casts. Some general conges- 
tion. No amyloid to Gentian violet. Typical tubercles with caseation and giant 
cells. Diagnosis : Parenchymatous nephritis. 

Case No. 7. — Phipps Institute Case. (Brinton and Stanton.) Abstract. 

No. 2238, Vol. 17. Male, age 25, single; occupation, waiter. First visit to 
dispensary 3-29-04; entered hospital 4-29-04; died 5-15-04. Diagnosis — Pul- 
monary tuberculosis with pneumothorax. Pneumothorax developed suddenly 
while in hospital. Duration of illness — 6 years. Sputum — T. b. present 
Heart — Normal, second pulmonic sound slightly loud. Pulse — 100 to 120; 
respirations 28; temperature 98 to 103. 

Bowels — 3-29-03 inclined to diarrhea ; 4-29-04 patient said he had slight 
diarrhea and had had several attacks. From time of entrance to hospital till 
death, 15 days, he showed once 3 and once 4 and 3 times 2 stools. Notes — 
4-5-04 bowels loose; 4-12-04 regular; 4-19-04 regular. 

Urine — 5-1-04 no albumin; 5-12-04 no albumin, sugar present, diazo 
present, excess of phosphates. 



2o6 NATIONAL ASSOCIATION FOR THE STUDY 

Autopsy (Rosenberger). 

Pathological Diagnosis: Pneumothorax right side; ulcerative tuberculosis 
of both lungs with widespread cavity formation; adhesive pleurisy; fatty in- 
filtration of liver; miliary tubercles in appendix; tuberculous pneumonia. 

Heart — 7 oz. ; normal. Spleen — 5 oz. ; normal. Liver — 3 lbs. 14 oz. ; 
large, dark and firm. 

Intestines — Normal. Appendix — Contains a few small yellowish areas 
resembling tubercles. Mesenteric Glands — Very slightly enlarged. Kidneys — 
Left 5J^ oz., right 6 oz. ; both organs pale and in some areas congestion is 
present. 

Microscopically: (Walsh.) 33 specimens studied. Glomeruli marked hya- 
line vacuolization of epithelium. Bowman's capsule connective tissue thickened. 
Epithelium of convoluted tubule swollen and necrotic. Lumen obliterated. Epi- 
thelium of secreting tubules of medullary rays swollen and necrotic. Intertubular 
tissue thickened. Congestion here and there. No infiltration. No amyloid to 
Gentian violet. Diagnosis : Mild diffuse nephritis. 

Case No. 8. — Phipps Institute Case. (McCarthy.) Abstract. 

No. 2262, Vol. 17. Male, age 57, married; occupation, cook. Entered 
hospital 4-5-04; died 6-13-04. Duration of illness — Since 1889. No edema. 
Sputum — Tubercle bacilli present. Heart — Normal, distinct accentuation of 
pulmonic second sound. Pulse — 100 to 120 ; respirations 24 to 30 ; temperature 
98 to 103. 

Bowels — Loose ; painful movements ; from i to 4 daily till death ; most 
frequently 2; frequently 3 and occasionally 4. 

Urine — 1028, albumin in slight quantities ; no sugar. 

Autopsy (Rosenberger). 

Pathological Diagnosis: Ulcerative tuberculosis of both lungs; miliary 
tuberculosis of both lungs; pleurisy, most marked on left side; parenchymatous 
nephritis; fatty liver with possible red atrophy; tuberculosis of the mesenteric 
glands; bed sores. 

Heart — 4^^ oz. ; small, pale, normal in shape and size. Spleen — Normal, 
6 oz. Liver — 2 lbs. 6 oz., firm, pale ; apparent dilatation of veins. Gall-Bladder 
— Small, walls thickened. 

Intestines — Normal. Appendix — Normal. Mesenteric Glands — Much 
enlarged and somewhat caseous. 

Kidneys : Left — 5 oz. ; slightly enlarged ; pale. Right — Smaller ; cortex 
thickened; medulla purplish, stellate veins prominent, surface smooth, 5^ oz. 
(Walsh.) Both kidneys cut into 140 to 150 pieces. One small cyst found and 
a few small yellowish areas looking like tubercles. 

Microscopically: 24 specimens studied. Glomeruli swollen; sometimes 
shrivelled, again fibroid. Connective tissue of Bowman's capsule thickened. 
Convoluted tubules dilated, sometimes cystic dilated, epithelium atrophic. Some- 
times desquamation of epithelium into tubules. Few hyaline casts. Thickening 
of interstitial connective tissue. No amyloid to Gentian violet. Several areas 
(i mm. in diameter) of round-celled infiltration, possibly young tubercles. 
Several typical tubercles with caseation and giant cells. Diagnosis : Chronic inter- 
stitial nephritis ; scattered tubercles. 

Case No. 9. — Phipps Institute Case. (Brown and Morris.) Abstract. 
No. 2344, Vol. 17. Female, age 35 ; occupation, housework. First visit to 
dispensary 5-4-04; entered hospital 5-12-04; died 8-10-04. Diagnosis — Tuber- 



AND PREVENTION OF TUBERCULOSIS 207 

culosis of both lungs ; tuberculous enteritis. Duration of illness — i year. No 
edema. Sputum — T. b. present. Heart — Normal. Pulse — 100 to no; res- 
pirations 32 ; temperature 98 to loi ; all three elevated towards the end. 

Bowels — 5-3-04 regular; 5-12-04 regular. These two represent the patient's 
own statement on the history sheet. 5-15-04 constipated; 6-20-04 diarrhea; 6-22- 
04 two stools daily ; 6-25-04, 5 to 6 daily ; 6-28-04 no better as regards diarrhea ; 
6-29-04 more comfortable; 7-1 1-04 diarrhea continues. From May i8th to June 
1st bowels usually one daily, from June ist to June 21st usually 2, frequently 3, 
twice 4 and twice 5; from June 24th to July 28th usually 3, once 4 and once 6; 
from July 28th till death 5, 4, 4, 7, 7, 7, 7, 7, 6, 7, 4, 2, 4, 5. 

Urine — 1020, clear, acid, trace of albumin. 

Autopsy (Rosenberger). 

Pathological Diagnosis: Ulcerative tuberculosis of both lungs ; bilateral 
pleurisy; fatty kidneys; congested liver; enlarged mesenteric glands; congestion 
of ileum. 

Heart — 8 oz. ; somewhat enlarged and flabby. Spleen — 7 oz. ; slightly en- 
larged ; no amyloid to iodine. Liver — 3 lbs. i oz. ; dark, mottled, veins 
prominent. 

Intestines — Ileum congested. Appendix — Normal. Mesenteric Glands — 
Enlarged. 

Kidneys: Left — 4 oz. ; no tubercles visible. Right — 5 oz. ; no tubercles 
visible, small, pale. (Walsh.) Kidneys cut into 140 to 150 small pieces. Num- 
erous small cysts filled with brown gelatinous material found. 

Microscopically: 33 specimens studied. Glomeruli swollen and hyaline, 
sometimes appearance of amyloid degeneration (haemotoxylon and eosin) again 
of pure hyaline degeneration. No amyloid in specimens stained with Gentian 
violet, though specimens so stained were poor and amyloid remains questionable. 
Bowman's capsule connective tissue thickened. Convoluted tubules dilated, 
epithelium atrophic. Numerous hyaline casts. Many convoluted tubules filled 
with debris. Several areas of round cell infiltration looking like young tubercles. 
One area of dense connective tissue looking like healed tubercle. Occasional 
localized infiltration between tubules. Several small cysts. Interstitial tissue 
generally thickened. No congestion. Diagnosis : Interstitial nephritis possible 
amyloid; probable scattered tubercles. 

Case No. 10. — Phipps Institute Case. (McCarthy.) Abstract. 

No. 2815, Vol. 21. Male, age 28, married. Entered hospital Oct. 8th, '04; 
died Nov. 9th, '04. Duration of illness — 9 months. Some swelling of feet. 
Sputum — T. b. present. Heart — Normal, accentuated pulmonic and aortic 
second. Pulse — 120 to 150; respirations 50 to 60; temperature 99 to 102. 

Bowels — Loose from time of entrance to hospital till death ; for 22 days 
preceding death bowel movement daily: 2, o, 3, 4, 3, 3, 3, 3, 4, 3, 4, 3, 3, 3, 
3. 2, 3, 4, 4, 5, 2, 2. 

Urine — No analysis. 

Autopsy (Rosenberger). 

Pathological Diagnosis: Ulcerative tuberculosis of both lungs; coalesced 
tubercles in both lungs; caseous pneumonia and emphysema of right lung; 
pleurisy; red atrophy of liver; dilatation of right side of heart; displacement of 
uterus to right ; enlarged mesenteric and bronchial glands. 

Heart — Slight displacement to right; right side dilated and shows chicken 
fat clot ; enlarged ; 8 oz. Spleen — 7 oz. ; slightly enlarged ; soft, darker than 



208 NATIONAL ASSOCIATION FOR THE STUDY 

normal; no amyloid. Liver — 4J4 lbs.; enlarged, extending nearly to umbilicus; 
dark. 

Intestines — Normal. Rectum and Ischiorectal region not examined. Ap- 
pendix — 7 cm. in length ; no ulcers present. Mesenteric Glands — Enlarged. 

Kidneys: Left — Movable; enlarged; dark red and presents slight striation 
of cortex ; 6 oz. Right — 6 oz. ; resembles left ; enlarged ; no tubercles present 
in either. (Walsh.) Both kidneys cut into 150 pieces. 

Microscopically: 13 specimens studied. Glomeruli — hyaline vacuolization 
of epithelium; some congestion. Bowman's capsule connective tissue thickened. 
Convoluted tubules — epithelium swollen, degenerated and necrotic. Occasionally 
round cell infiltration between tubules, also between the cells of the convoluted 
tubules. Epithelium of secreting tubules of medullary rays necrotic. Rare 
hyaline casts. Rare fibroid glomerulus. No amyloid to Gentian violet. Typical 
tubercles with caseation and giant cells. Diagnosis: Parenchymatous nephritis; 
scattered tubercles. 

C>SE No. II. — Phipps Institute Case. (Ravenel.) Abstract. 

No. 2926, Vol. 21. Female, age 19, single. Entered hospital Nov. 26, '04; 
died Dec. 22, '04. Duration of illness — 3 years. No edema. Sputum — T. b. 
positive. Heart — Reduplicated first sound. Pulse — no to 140; respirations 
35 to 45 ; temperature 97 to 100. 

Bowels — Loose ; Nov. 29th diarrhea ; Dec. 6th diarrhea quite bad and 
painful; from Nov. 27 4, i, 6, i, i, 2, 4, 5, 3, 4,2,3,4,5,2,5,3,4,3,3,2,2,0,2,0,0. 

Urine — 1024, pus, albumin, no sugar, diazo slight. 

Autopsy (White). 

Pathological Diagnosis: Tuberculosis of both lungs with cavity formation; 
tuberculosis of the bronchial and mesenteric glands and of the appendix ; dilated 
right and left ventricles; parenchymatous nephritis. 

Heart — Right ventricle walls thin and cavity twice normal size ; left 
ventricle walls thin and cavity one and one half times normal size. Spleen — 
Normal. 

Intestines — Normal. Appendix — Contains considerable hardened feces 
and showed 5 small ulcers one-eighth of an inch in diameter. Mesenteric Glands 
— Slightly enlarged. 

Kidneys: Left — Normal in size; pale in color; normal consistency; cap- 
sule reasonably adherent. Right — Normal in size ; pale in color ; normal con- 
sistency; capsule reasonably adherent. (Walsh.) Both kidneys cut into 140 to 
150 small pieces. One cyst, ^ by i^ inches, in cortex filled with gelatinous 
caseated material. No tubercles found. 

Microscopically : 26 specimens studied. Glomeruli swollen, congested ; epi- 
thelium shows hyaline vacuoles. Bowman's capsule connective tissue thickened. 
Occasional glomeruli fibroid. Small hemorrhagic infarct about 5 by 6 mm. 
Various small areas of infiltration, especially under capsule. In localized areas 
convoluted tubules show epithelium necrotic; interstitial tissue thickened. No 
amyloid to Gentian violet. No distinct tubercles found. Diagnosis: Diffuse 
nephritis. 

Of the eleven cases nine showed some abnormaHty of the Hver. 
Some diseases of the hver may give rise to diarrhea, but in them other 
symptoms are prominent which did not exist in these cases. Six cases 
showed inflammation of the appendix. Appendicitis may give rise to 



AND PREVENTION OF TUBERCULOSIS 2O9 

diarrhea, but usually causes constipation. Seven cases had enlarged 
mesenteric glands. Diseased mesenteric glands are credited with pro- 
ducing diarrhea, but even here there is some doubt, as there usually 
is associated with them ulceration of the bowels. In seven there was 
abnormality of the heart. Heart disease can only produce diarrhea 
by setting up hyperaemia in the abdominal organs. In one case the 
liver, appendix, mesenteric glands and heart were all normal, and yet 
the diarrhea and nephritis were marked. 

In two of the cases an abnormal condition of the thyroid gland was 
found by Dr. Wm. B. Stanton. One showed tubercles and the other 
simple enlargement. Enlargement of the thyroid is sometimes accom- 
panied by diarrhea. 

In only three cases was edema recorded as being present. It 
probably was present in some others but was overlooked or not re- 
corded. In six cases, however, there was a record of no edema. It 
may at least be inferred that edema is not a marked symptom. The 
absence of edema is most remarkable in Case XIII in which the autopsy 
revealed a dilatation of both sides of the heart. 

In five cases there was albumin in the urine. In three there was 
none. One of the remarkable features of nephritis in tuberculosis is 
the non-elimination of albumin. Even when the kidneys are extensively 
diseased there is very little albumin in the urine and sometimes there is 
none. In one case there were hyaline and granular casts in the urine, 
in one case there were no casts, in nine cases no record was made upon 
the subject of casts. The probabilities are that hyaline or granular 
casts would have been found in all if careful search had been made for 
them. Hyaline or granular casts seem to occur in all cases of nephritis 
associated with tuberculosis. 

The specific gravity of the urine was 102Q and over in four cases 
and below 1020 in one case. In six cases no record was made of the 
specific gravity. In tuberculous nephritis the specific gravity of the 
urine usually is very high. In cases in which loose bowels exist this 
high specific gravity may be due to the amount of fluid carried off by 
the bowels. 

In seven of the cases the pulse was above 120 and in four it was 
below 120. For most of the cases the pulse record was a bed record. 
High pulse in tuberculosis is always suggestive of nephritis. The char- 
acter of the pulse has not been recorded. Usually it is thready. 

Nephritis occurs very frequently in tuberculosis. It is caused by 



2IO NAT. ASS'N for STUDY AND PREV. OF TUBERCULOSIS 

the growth of tubercle bacilli in the tissues of the kidney and by the 
toxin excreted through the kidneys from lesions elsewhere. It also may 
be caused, perhaps, by the dead tubercle bacillus in the process of elimi- 
nation. That the tubercle bacillus escapes from the body by way of 
the kidney can no longer be doubted. Whether it escapes only with 
broken down tubercles in the kidneys or also by elimination is unsettled. 
In a study of the urine in tuberculosis made three years ago (Proc. 
Phila. Path. Soc, Apr., 1903) we reported the finding of tubercle ba- 
cilli in the urine in forty-four out of sixty cases. 

Grancher and Martin reported in the Revue de la Tuherculose 
for 1893 a series of experiments upon dogs for the establishment of 
immunity with gradually increasing doses of avian tubercle bacilli in 
which the ultimate outcome frequently was nephritis either bacillary or 
toxic. The longer the animal lived and the more resistant it became the 
greater were the chances of a nephritis. 

Clinically nephritis is one of the complications in tuberculosis most 
to be dreaded. This is the more so because it is a complication which 
comes on with the very process which leads to recovery, namely, im- 
munization. When established it becomes a menace to life. Many 
cases of tuberculosis die by way of nephritis as the real cause of death. 

The symptom complex by which nephritis in tuberculosis may be 
recognized is a pasty skin, unusual fatigue upon slight exertion, short- 
ness of breath, rapid thready pulse, high specific gravity of urine, 
hyaline and granular casts at times, tubercle bacilli in the urine at times 
and slight amount of albumin at times. Edema may be present but is 
not as a rule. Frequently there is looseness of bowels alternating with 
constipation and sometimes there is continuous diarrhea. Albumin and 
casts are more apt to be found when something has occurred to congest 
the kidneys. 

We have found sulphate of magnesia and nitroglycerine of greatest 
use in the treatment of this complication. When the bowels are very 
loose twelve grain doses of sulphate of magnesia every hour will lessen 
the number of stools. When the bowels are costive the magnesia will 
greatly improve the general condition. Sometimes patients begin to 
gain in weight under the use of sulphate of magnesia who have done 
badly before. Opiates should never be used in these cases. 



NOTE ON THE STABILITY OF THE CULTURAL 
CHARACTERS OF TUBERCLE BACILLI, WITH 
SPECIAL REFERENCE TO THE PRODUCTION 
OF CAPSULES 

By Theobald Smith^ M. D. 

(From the Laboratory of Comparative Pathology, Harvard Medical School) 



In the artificial cultivation of bacteria, which has played so im- 
portant a role in the development of bacteriology, there are two diver- 
gent phenomena which arrest our attention. The first is the remark- 
able stability of certain characters of bacteria during prolonged arti- 
ficial life in the culture tube, the second is a tendency of certain other 
characters to change or vary under the same conditions. It is this 
latter tendency which is worthy of more thorough study. Among the 
variable characters are those relating to the capsules or envelopes of 
bacteria and those relating to virulence or pathogenic power. 

In the present paper I wish to call attention briefly to the first- 
mentioned of these variable elements which probably exercises more 
or less influence upon the physical characters of bacteria in general 
and of the tubercle bacillus in particular. 

The significance of the outer membrane or envelope of the par- 
asitic bacteria in their struggle with the hoet has been frequently 
touched upon in bacteriological literature. The difficulty of bringing 
exact proof as to what may be the actual functions of a bacterial en- 
velope has been so great that nothing definite can be stated at present, 
and thus far any visible membrane or capsule has been used chiefly 
to serve in diagnosis and classification. 

Those who have attended to the cultivation of bacteria over long 
periods of time may have witnessed changes in the same culture which 
appear to be directly traceable to some modification of the bacterial 
envelope. After prolonged cultivation certain bacteria agglutinate 
spontaneously. I have observed this in hog-cholera and typhoid bacilli. 



212 NATIONAL ASSOCIATION FOR THE STUDY 

Among the races of rabbit- septicaemia bacilli the earliest cultures 
are of normal character, but in all after a time, with some promptly, 
with others only after years of cultivation, the growth becomes viscid, 
mucus-like. This is easily recognized in the condensation water of 
agar tubes. 

In cultures of glanders bacilli the growth after a few generations 
becomes excessively viscid, so that the morphology of the bacilli ap- 
pears very different from that of the earliest growths. 

The avian tubercle bacillus possesses certain initial characters 
which readily separate it from the mammalian races. One strain 
which I carefully observed from the start grew at first diffusely in 
bouillon without membrane formation, but after a certain time patches 
appeared on the surface and after repeated transfers only a coherent 
surface growth prevails. 

Among diphtheria bacilli, the early growths in bouillon are dif- 
fuse, but after repeated transfers the cohesive character of the culture 
slowly appears and leads finally to the surface growth in form of a 
continuous membrane. 

I have furthermore noticed that certain races of hog-cholera bacilli 
are viscid from the start. 

In the cultivation of the tubercle bacillus the peculiar behavior of 
these bacilli first and last is best explained by assuming some change 
in the envelope or outer membrane of the bacilli. It is well-known 
that it is very difficult and frequently impossible to obtain cultures of 
tubercle bacilli from tuberculous tissue in culture media in which they 
will grow readily after months or years of artificial cultivation. To 
obtain original cultures it is necessary to approximate as closely as 
possible the conditions obtaining in the animal body. 

We can interpret this great change which the bacilli undergo in 
artificial cultures in two ways, i. They make use of substances which 
at first could not be utilized as food. In other words their metabolic 
functions have undergone a profound alteration. 2. The bacilli under 
artificial cultivation have eliminated something which has interfered 
with active absorption and assimilation. 

I am inclined to accept the second theory and assume that in the 
course of artificial cultivation a relatively impervious protective cap- 
sule has been gradually eliminated or modified, and as a result the 
growth and multiplication has become freer and more rapid. This 
elimination or modification of the envelope may go on by a selective 



AND PREVENTION OF TUBERCULOSIS 2I3 

growth of those bacilli which are most easily affected, or else the mem- 
brane may become modified in all bacilli because the active struggle 
with living tissue has been in abeyance. 

This phenomenon may be frequently observed in cultures of the 
tubercle bacillus on glycerine bouillon. The patch of transferred bacilli 
remains apparently dormant for a time, then there is a growth in 
thickness as if the multiplication took place chiefly within the original 
patch. Quite suddenly a delicate film appears on the edge of the patch 
at one or more points, and within a relatively short time this film has 
covered the entire surface of the bouillon. It appears as if some bacilli 
had thrown off a restraint while others were unable to do so. 

The change which these observations suggest is one of softening 
and perhaps degeneration of the outer membrane of the bacillus. This 
membrane in the bacilli isolated recently from living tissues may be 
pictured as firm, non-viscid, whereas the membrane of those under 
artificial cultivation is apparently overproduced, and of a viscid cohe- 
sive character. This is noticeable in the highly specialized bovine 
tubercle bacilli. In the earliest cultures the growth is nearly free from 
the cohesiveness almost general in the earliest cultures of the more sap- 
rophytic human bacilli. The latter probably multiply in cavities and in 
mucus, whereas the bovine bacilli have little or no opportunity of this 
kind in the body of cattle. This change in the physical characters of 
cultures runs parallel with gradual loss of virulence, but the causal 
relation between the two must rest upon conjecture for the present. 

The different degrees of cohesiveness of bacteria occurring at 
different stages of artificial cultivation may modify profoundly the 
grouping of bacteria in colonies, and hence their microscopic and 
macroscopic appearance. There may also exist differences traceable 
to race peculiarities. 

Some years ago the different cohesiveness of bovine and human 
cultures led me to study the form of very young colonies of tubercle 
bacilli on blood serum in order to determine if such differences might 
be utilized in classification. 

The method adopted for the study of young colonies was the one 
of W. Hesse slightly modified.^ Dr. Hesse used Petri dishes and agar 

*The immediate impulse to these studies was given by Dr. Hesse himself. 
During a visit to my laboratory Dr. Hesse was successful, from a cursory ex- 
amination of stained smears of tubercle bacilli from various sources, in dis- 
tinguishing human from bovine cultures, by the grouping of the bacilli. See 
Ztschr. Hygiene, XXXI, p. 502. 



214 NATIONAL ASSOCIATION FOR THE STUDY 

with Nahrstoff Heyden to cultivate the bacilli in sputum. I used large 
test-tubes, six by one and one-haif inches, stoppered with cotton in 
which a large cork was imbedded to limit drying as much as possible. 
Horse serum, to which some bouillon and glycerine had been added, 
was set at about seventy-eight to eighty degrees Centigrade. A thor- 
oughly sedimental suspension of a culture of tubercle bacilli was pre- 
pared by rubbing on the inside of dry sterile test-tubes some of the 
growth and then adding sterile water or bouillon. The serum was 
inoculated by adding several drops of the suspension and thoroughly 
rubbing it over the entire surface. The tubes were incubated in such 
a position as to ensure a nearly level surface for the serum layer. 
After a number of days varying from three to eight, " Klatsch " prep- 
arations were made according to Hesse by placing on the serum a 
flamed cover-glass, gently prying up the edge and allowing the cover- 
glass to swing on the other edge as a hinge until it could be grasped 
by a pair of slender forceps, and removed. The tube may be examined 
two or three times by laying cover-glasses on still untouched portions 
of the slanting surface. The large tubes were used in place of the 
Petri dishes to reduce evaporation and contamination to a minimum, 
since preparations from cultures younger than four days are rarely 
of any value and Petri dishes soon become both dry and infected. 

Horse serum was used in place of dog serum owing to the large 
amounts needed in the large test-tubes. This was a drawback, since 
very young bovine cultures grow feebly or not at all on this medium. 
However, the object of the study was not so much to determine initial 
differences as to find those remaining after prolonged artificial cul- 
tivation. 

A careful microscopic study of the many colonies transferred to 
cover-glasses did not reveal anything that could be considered a dis- 
tinguishing mark between the different races of bacilli. The reason 
for the negative outcome is probably due to the fact that the bacilli 
thus compared had already been under artificial cultivation for some 
time and more or less modified by this process. Attention has already 
been called to the slow change in the characters of tubercle bacilli 
during cultivation. Most likely there had been going on a change 
which brought nearer together races originally divergent. But what- 
ever the significance of these original differences, they are of no value 
in classifying these bacilli since they tend to disappear. 

Thus far I have dealt only with physical conditions of the mass 



AND PREVENTION OF TUBERCULOSIS 215 

of bacteria which point to changes in the outer envelope of tubercle 
bacilli. There are evidences derived from microscopical examination 
v^^hich point to the existence of capsular substance. 

By the ordinary procedure of staining tubercle bacilli in hot carbol- 
fuchsin and subsequent decolorization in mineral acids, there is fur- 
nished no indication that tubercle bacilli produce capsular or a similar 
enveloping substance. When tubercle bacilli are stained in cold carbol- 
fuchsin for twenty to thirty minutes and then treated with a very dilute 
solution of acetic acid such as one-tenth per cent, the indications given 
by such cover-glass preparations point strongly to some envelope.^ In 
the first place the cold stain penetrates slowly and within the time given 
the rods frequently appear white upon a feebly tinted background. 
Occasionally there is a thin axial line stained feebly in the otherwise 
uncolored rod. After more prolonged staining the dye penetrates and 
the rods become stained. By restricting the decolorizing agent to one- 
tenth per cent acetic acid as indicated above, an unstained halo is fre- 
quently seen around the well-stained rod. No special attempts to dif- 
ferentiate this envelope by means of stains has been made. 

The parallel study of cultures from human and bovine sources 
has shown that this substance is more abundant in human than in 
bovine bacilli and that it increases with the length of artificial cul- 
tivation on serum. As a rule bovine bacilli absorb cold carbol-fuchsin 
more promptly than human bacilli. The bovine bacilli when the con- 
ditions are favorable for the production of capsular substance show 
an unstained halo about each rod, whereas in human cultures, the 
bacilli are more commonly fused into masses and individual capsules 
are not definable. The capsular substance forms a kind of matrix in 
which the bacilli are embedded. The condition most favorable for 
capsule production is a somewhat soft, yielding serum. Bacilli grown 
in such serum refuse the stain in direct proportion to the capsular sub- 
stance present. 

Peculiarly modified bacilli are not infrequently encountered in 
bovine cultures and their derivatives, parasitic in other species, espe- 
cially in bacilli that have been isolated for a year or longer. When 
stained in carbol-fuchsin and treated either with ten per cent sulphuric 
or one-tenth per cent acetic acid, the bacilli appear as deeply stained, 
very short plump rods, with very feebly stained prolongations at either 

* For the early literature concerned with a probable envelope of tubercle 
bacilli, see Unna, Centralbl. f. Bak. Ill, 1888, p. 95 et seq. 



2l6 NATIONAL ASSOCIATION FOR THE STUDY 

end and the whole strongly simulates a bacillus containing a stained 
spore, the bacillus being in a state of partial disintegration (Plate i, 
figs. 2, 4). These rods would probably suggest to any one not famil- 
iar with them the presence of contaminating spore-bearing bacilli in 
what should be a pure culture of tubercle bacilli.^ 

The interpretation of this phenomenon as an overproduction of 
capsular substance is the simplest at hand at present. It does not 
occur in any human cultures which I have studied, but seemed to be 
limited to bovine cultures and to the horse culture, a derivative of the 
former. It is also in all probability a sign of degeneration of the bacilli 
in artificial cultures. This inference is strengthened by observations 
made upon two cultures of Bovine VIII one of which had been passed 
through a series of rabbits and the other grown only on artificial media 
(Plate I, figs, I, 2). In the original culture this capsular substance 
is quite conspicuous but it is absent in the culture from the last of the 
series of rabbits. 

Whether these two elements, the enveloping capsule and the 
feebly-stained or nearly unstained tails of bacilli are different products 
or simply modifications of the same, must be left for future studies to 
decide. 

Allied to the formation of capsules was a phenomenon noticed in 
cultures contaminated by a large bacillus. The influence of the con- 
taminating organism, either exerted directly or indirectly upon the 
bacilli, was sufficient to modify temporarily to such a marked degree 
the microscopic characters of the bovine tubercle bacillus as to make 
it resemble the human type. 

It has already been stated in former publications that the distin- 
guishing characters upon blood serum media in the earliest stages of 
artificial cultivation are: i. The short straight, somewhat plump rod- 
like form of the bovine bacillus as contrasted with the longer, more 
slender and slightly curved form of the sputum or pulmonary type of 
the human bacillus, 2. The much greater tendency of the human 
bacillus to cohere in compact colonies of curved outlines. Both these 
distinguishing characters were practically wiped out in the mixed 
cultures. The details of the observation are briefly as follows: In 
1899 conditions favoring the softening of the blood serum were ac- 

^ See also Wolbach and Ernst, Journ. Med. Research, X, 1903, p. 313. 
Some of the photomicrographs in this paper (notably fig. 47) probably represent 
the same phenomenon. 



AND PREVENTION OF TUBERCULOSIS 21/ 

cidentally brought about in my cultures by the presence of a spore- 
bearing bacillus which had slowly penetrated the entire serum and 
changed it from a firm, opaque, to a jelly-like translucent mass. Nearly 
all the stock cultures were involved. An examination of the growth 
on the surface of this softened mass revealed an unexpected sight. 
The cultures marked bovine had largely assumed the characters of 
the human type. Instead of being short they were long and slender 
and slightly curved. Moreover in place of being arranged irregularly 
in the smear the bacilli appeared in dense coherent fusiform bundles 
(Plate II, figs. I, 3). 

At first sight, the suspicion was aroused that the cultures had 
become interchanged; but as no person was permitted to handle them 
I gave this suspicion no further thought since three bovine and one 
cat culture of bovine type were modified in the same way. The next 
step was to purify the cultures by passing them through rabbits or 
guinea-pigs. In the three cases tried this was successful. The cul- 
tures assumed their original characters after recovery from the ani- 
mals, as is shown by the photomicrographs (Plate II) of smears from 
the cultures before and after purification. 

The interpretation of this temporary modification is an increase 
in the production of the cohesive capsular substance or else some 
modification of the bacillar membrane whereby it swells up and be- 
comes recognizable and evidently more sticky. 

The capsules are not shown in the reproductions, because the 
decolorization had to be pushed until clear outlines of bacilli were ob- 
tained. They were, however, quite conspicuous in other preparations 
from the same cultures. 

A careful measurement of the bacilli stained in the usual way 
with hot carbol-fuchsin and decolorized with a mineral acid and after 
staining in cold carbol-fuchsin was made. The latter including cap- 
sule were broader by fully one-half than the former. 

A somewhat similar increase in the length of the bacilli was re- 
cently described by C. N. McBryde.^ Tubercle bacilli from cattle and 
swine growing on egg media in contact with paraffine were found 
much longer than those at some distance from the paraffine. No 
mention is made of the presence of a capsule around these modified 
bacilli. 

^ 30th Annual Report of the Bureau of Animal Industry, Washington, 
1903, p. 109. 



2l8 NATIONAL ASSOCIATION FOR THE STUDY 

As regards the nature and significance of the capsular substance 
of tubercle bacilli two hypotheses may be formed. According to one 
we have before us a product of secretion, according to the other an 
overproduced outer membrane. I am inclined to accept the latter 
view as already stated. The culture medium seems to exercise a pre- 
dominant influence, and in the culture medium the blood serum ap- 
pears to be the specific influencing factor in the production of a cap- 
sule. There is much similarity between this substance and the sub- 
stance which makes up the clubs in Actinomyces. Wright's obser- 
vation^ that clubs tend to appear in culture media made up of serum 
or other animal fluids and the writer's that softened serum, espe- 
cially that part partly digested by bacteria is likely to lead to capsule 
formation in tubercle bacilli,-tend to favor this view. 

The difficulties surrounding a study of the conditions under 
which capsular substance is produced are considerable, since very 
slight differences in the physical and chemical characters of those 
culture media which consist chiefly of blood serum are not readily con- 
trolled. Moreover in any culture tube, the bacilli are under a variety 
of conditions. Some are directly in contact with the surface of the 
culture medium, others not; some are vegetating on a drier medium 
in the upper part of the tube. As a result the microscopic examination 
of different portions of the same culture often shows bacilli differing 
considerably from one another as regards capsule production, and 
inferences must be drawn with caution. 

Though the results of my own studies are very meager, they 
nevertheless should stimulate to further studies and the writer hopes 
that this paper may aid in inducing others to pursue the investigation 
of the capsular substance of tubercle bacilli with greater detail and 
accuracy than has been done hitherto. 

Concerning the relative stability of the characters of the several 
races of tubercle bacilli, which is still a burning question in some 
quarters, the sum of observations made up to the present indicates that 
they are remarkably constant, provided the conditions remain abso- 
lutely uniform. As soon as these change certain changes may appear 
in the cultures. In fact it would seem as if tubercle bacilH show 
slightly different characters on every new medium used. When we 
return to former conditions, the variations disappear. These facts 

* The microorgan'.sm of actinomycosis. Journ. Med. Research, 1905, XIII, 
P- 349. 



AND PREVENTION OF TUBERCULOSIS 2I9 

prove how important it is to control with great care all the conditions 
surrounding the cultivation of tubercle bacilli, especially in the com- 
parative studies of bacilli from different species. 

Description of Plates 

The photomicrographs were prepared by Mr. L. S. Brown at the 
clinico-pathological laboratory of the Massachusetts General Hospital 
through the courtesy of Dr. J. H. Wright, the director. 

The preparations reproduced on Plates I and II are simple smears 
on cover-glasses prepared by gently rubbing two cover-glasses together 
with the particle of culture material between them. No diluent was 
employed. The cover-glass preparations after thorough drying were 
drawn through the flame, stained in hot carbol-fuchsin for three to 
five minutes, decolorized in ten per cent, sulphuric acid by volume for 
about thirty seconds, and mounted in xylol balsam after washing and 
drying. For the history of the cultures used, see Journ. Exp. Med. 
1898, III, p. 451, and Journ. Med. Research, 1905, XIII, p. 253. 

Plate I, fig. I. Culture Bovine VIII, passed through a series of 
rabbits. On dog serum, ten days old. 

Fig. 2. The same stock cultivated artificially for over two years 
through twenty-four transfers. Culture on dog serum ten days old. 
In fig. 2 the bacilli appear as deeply-stained very short rods, continued 
at both ends into feebly-stained prolongations. 

Fig. 3. Culture Horse I. Eighth transfer. Culture on dog serum 
fourteen days old. This is probably a derivative of the bovine race 
of bacilH. 

Fig. 4. The same on dog serum, ten days old. Fifty-seventh 
transfer. In this figure, the bacilli show feebly-stained prolongations 
of considerable length, simulating spore-bearing bacilli with the spores 
stained. 

Plate II, fig. I. Bovine II. Culture on beef serum more or less 
softened by being permeated with a large (anaerobic) bacillus. Culture 
seventeen days old. 

Fig. 2. ,The same culture after it had been purified by being 
passed through a guinea-pig. Culture on dog serum, twenty-seven days 
old. ( Note the increased length of the bacilli in the contaminated culture 
as well as the marked cohesiveness indicated by the heavy black masses 
representing tubercle bacilli packed together. In fig. 2 the bacilli are 
short again and more easily spread.) 



220 NAT. ASS N FOR STUDY AND PREV. OF TUBERCULOSIS 

Fig. 3. Culture Cat I, on the same contaminated medium as 
above.^ Culture, thirty-five days old. 

Fig. 4. The same after having been passed through a guinea-pig 
to remove the contaminating bacillus. Culture on dog serum twenty- 
seven days old. 

^ It should be stated that the beef serum cannot be held responsible for 
this modification for the reason that contaminated cultures on dog serum pre- 
sented the same appearance and pure cultures on beef serum did not 



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THE VITALITY OF TUBERCLE BACILLI 
IN SPUTUM 

David C. Twichell, M. D., 
Saranac Lake 



This experiment was undertaken to prove how long the tuber- 
cle bacillus would live in sputum under natural conditions, it being of 
interest to know for how long a period the tubercle bacillus in sputum, 
in articles such as handkerchiefs, or in rooms or public places may re- 
tain its vitality, and relative to the question as to the danger of sputum 
as a cause of infection. 

Villemin^ found that dried sputum preserved its virulence after 
several weeks. 

Experiments of Koch,^ Schill,^ Fischer, and others, have shown 
that the bacilli retained their vitality in desiccated sputum for several 
months (nine to ten, De Thoma*) but they are said to undergo a grad- 
ual diminution in pathogenic virulence, which is more rapid when the 
desiccated material is kept at the temperature of thirty to forty degrees 
C. Koch dried sputum at the temperature of the laboratory for four 
to eight weeks and found it still would produce tuberculosis in animals."* 
In his address before the Tenth International Medical Congress, Berlin, 
1890, he stated that when exposed to direct suijlight the tubercle bacilli 
are killed in from a few minutes to several hours, according to the 
thickness of the layer. He also stated that they are destroyed by diffuse 
daylight in from five to seven days when placed near a window. 

'"De la propagation de la phtisie" (Memoire lu a I'Acad. de medecine 

*"Die Aetiologie der Tuberculose" (Berlin, klin. Wochenschrift, S. 

'"Ueber die Desinfection des Auswurfs der Phthisiker" (Mittheil. a. d. 
kais. Gesundheitsamte, Bd. 2, S. 133, 1884). .. ,, . , j. „ _,. 

* " Sulla virulenza dello sputo tubercolare iAnnalt Universale at Medtca, 
luglio, 1886). 

'"Bacteriology." Sternberg, page 385. 



222 NATIONAL ASSOCIATION FOR THE STUDY 

Malassez and Vignal^ found that sputum alternately dried and 
moistened for twelve days was yet virulent. 

Sawizky^ found that sputum, subjected to the ordinary conditions 
of the floors of a dwelling-house, preserved its virulence for a period 
of two to two and one-half months, and that there was no difference 
between the sputum obtained from dark corners and that which had 
been exposed to the sun's rays. 

Migneco^ found that sputum dried on handkerchiefs in the 
sunlight preserved its virulence for eighteen hours, while sputum 
dried on woolen cloth in sunlight preserved its virulence for thirty 
hours. 

Dr. Arthur Ransom* and Mr. Sheridan Delepine, in a series of 
experiments, found that sputum exposed to light and air for forty-five 
days in June and July did not produce tuberculosis when inoculated 
into rabbits; that sputum exposed in an air shaft at dusk during the 
same season produced slight tuberculosis; that the same sputum ex- 
posed at the same time to light and air produced no tubercle in a guinea- 
pig. The same methods employed, only at dusk, produced advanced 
tuberculosis. Another sputum exposed in April for sixteen days to 
little or no air in darkness, produced well marked tuberculosis. Spu- 
tum dried on paper for twenty-four hours and placed in a dark, close 
cupboard for one day produced well marked tuberculosis. Sputum 
kept under the same conditions and exposed to a little air for thirty- 
five days produced distinct local tuberculosis. Sputum placed in the 
air-shaft of a draught-closet in a dim light, pure air passing through 
it for three days, at ordinary temperature, caused well marked tuber- 
culosis. Sputum exposed to light for three days, with an hour of sun- 
shine, good ventilation, and a maximum temperature of 50 degrees 
Fahrenheit, produced no tuberculosis. Other sputum exposed to light 
for seven days, with fifteen hours of sunshine and brisk ventilation, 
did not cause tuberculosis. Again, sputum exposed to the light for two 
days after having been kept dried for four weeks (there had not been 
much exposure to sunshine and ventilation had been slight) produced 
no tuberculosis. 

* C. r. de la Soc. de Biol, page 366, 1883. 

' " Zur Frage uber die Dauer der infectiosen Eigenschaften des getrock- 
neten tuberculosen Sputums " (Dissert, inaug., Saint-Petersburg, 1891 ; analyse 
in Centralb. fiir Bakteriol., Bd. 11, page 153, 1892). 

* Archiv fiir Hygiene, Bd. XXV, No. 4, 1896. 

* No. 336. Proceedings of the Royal Society. 



AND PREVENTION OF TUBERCULOSIS 223 

Comet ^ says — " After about six months expectorated material 
contains not a single germ capable of further development." 

The material used in our experiment was obtained by mixing in 
equal proportions the sputum of two patients, in whom the disease was 
actively progressing, so as to make reasonably sure of obtaining a viru- 
lent, strongly growing organism. 

The number of bacilli present in the sputums used showed from 
vii - viii on Gaf fky's scale. 

The sputum from each patient was first tested by injecting 0.5 c.c. 
into the groins of two guinea-pigs. Ninety-one days later the first pig 
was killed. The pig was emaciated and showed a large open ulcer in 
the right groin. Tubercle bacilli were obtained from the ulcer. The 
inguinal glands were enlarged and caseated, and the spleen showed 
tubercles. After one hundred days the second pig was killed. On 
autopsy it showed generalized tuberculosis. 

The following are the conditions in which the sputum was placed : 

I St. Sputum deposited in sterilized, corked and paraffined white 
glass bottles (the bottles were 3 ctm. in diameter and a depth of about 
I ctm. of the mixed sputum was placed in each bottle). 

A. In a dark, moist box. 

B. In a dark closet. 

C. In the diffuse light of an ordinary room. 

D. In the sunlight on glass plates (a fairly thin layer of 
sputum on a Petri dish). 

E. In the thermostat. 

2nd. Sputum deposited in sterilized white glass bottles stopped 
with cotton. 

A. In a dark, moist box. 

B. In a dark closet. 

C. In the diffuse light of an ordinary room. 

D. In the thermostat. 

3rd. Sputum deposited in sand in sterilized white glass bottles. 

A. In a dark, moist box. 

B. In a dark closet. 

C. In the diffuse light of an ordinary room. Bottle corked 
and paraffined. 

D. In the diffuse light of an ordinary room. Bottle not 
sealed. 

^ " Tuberculosis." Cornet, page 83, edition 1904. 



224 NATIONAL ASSOCIATION FOR THE STUDY 

E. In the thermostat. Bottle not sealed. 

F. In the thermostat. Bottle corked and paraffined. 
4th. Sputum deposited under ordinary room conditions on: 

A. Handkerchief (folded). 

B. Carpet. 

C. Wood. 

D. Woolen blanket (folded). 

5th. Sputum deposited in the open air during the winter months, 
in open, white glass bottles. 

6th. Sputum deposited in sterilized, white glass bottles, corked 
and paraffined ; buried in the ground. 

7th. Sputum deposited in sterilized, white glass bottles packed 
with ice, corked and paraffined, frozen in blocks of ice. 

In the experiment with sputum exposed to sunlight, the specimens 
when not actually exposed to the sun's rays were kept in a dark box. 

The experiment with the sputum placed in sand was not satisfac- 
tory. Many pigs died early of septicaemia. The sand was not steril- 
ized and the reclaiming of the sputum from the sand was not certain. 

The experiment with the sputum placed in blocks of ice was not 
entirely satisfactory, as it was not possible to keep the bottles frozen 
solid. 

At stated intervals, the sputum under these various conditions was 
tested by subcutaneous injection into the groins of guinea-pigs. 0.25 
c.c. of the sputum was injected into both groins of each pig, and was 
introduced by a glass hypodermic syringe. The site of injection was 
washed with five per cent, carbolic acid, and the syringe was carefully 
boiled between each injection. 

One pig was inoculated with each sample of sputum to be tested. 
If at the end of two or three weeks there was no enlargement of glands, 
a second pig was inoculated with the same material. After a certain 
length of time, usually from a month to six weeks, pigs, if still living, 
were killed. At autopsy, smears from glands and tubercles were made 
and examined under the microscope. 

The following tables show the results of our experiments on the 
vitality of the tubercle bacillus in sputum under the various conditions 
as detailed above. 



AND PREVENTION OF TUBERCULOSIS 



225 





H >> 




DEATH 


RESULTS OF AUTOPSY 




Conditions 
of 


SQ 








Result 




U 




GLANDS 










+ 


Experiment 


03 
V a 
gcfl 




Cause 


Inguinal 


Retro-peritoneal 


S 


C3 


8 


> 




or 





H"o 


Q-" 








h-) 


Vi >J 


1^ 




la. 


108 


54 


Killed 


Enlarged 


Enlarged 1 + 





+ 








+ 


Sputum in 








Caseated 


Caseated 












corked and 


141 


37 


Killed 


Enlarged 


Enlarged + 





+ 








+ 


paraffined 








Caseated 


Caseated 














white glass 


170 


16 


Killed 


Enlarged 


Enlarged 


+ 














+ 


bottles 








Caseated 
















Dark moist 


188 


42 


Killed 


Not enlarged 


Not enlarged 




















box 


196 


42 


Killed 


Not enlarged 


Not enlarged! O 

















lb. 


137 


41 


Killed 


Enlarged Enlarged 


+ 














+ 


Sputum in 








Caseated 
















corked and 


160 


2S 


Killed 


Enlarged 


Enlarged 


+ 














+ 


paraffined 








Caseated 
















white glass 


188 


42 


Killed 


Not enlarged 


Not enlarged 




















bottles 
























Dark closet 


196 


42 


Killed 


Not enlarged 


Not enlarged 




















Ic. 


124 


21 


Undetermined 


Enlarged INot enlarged + 














+ 


Sputum in 








Caseated 














corked and 
paraffined 


175 


32 


Killed 


Not enlarged Not enlarged 




















white glass 








1 














bottles 
Diffuse light 


189 


43 


Killed 


Not enlarged Not enlarged 




















ordinary room 























II 





g 


Hours 

in 
direct 
sun's 
rays 


DEATH 


RESULTS OF AUTOPSY 


Result 


Conditions 
of 
£ xperimen 


l§! 


GLANDS 


1 

3 


a 

0) 

"3. 


ii 

> 

2 


1 


+ 


It 


CAUSE 


Inguinal 'Retro-peritoneal 


s 


or 



Id. 
Sputum on 
^lass plates 
m sunlight 


I 

I 
10 


I 
7 

24i 


40 

42 
40 


Killed 
Killed 

Killed 


Enlarged i Enlarged 

Caseated 1 Caseated 

Not enlarged Not ehlarged 

Not enlarged Not enlarged 


+ 









+ 

















+ 






Conditions 
of 


£5. 

I« 

0. 

X a 

\Z ^ 
3 

gW 

H"o 


DEATH 


RESULTS OF AUTOPSY 


Result 


l| 

p 


Cause 


GLANDS 


a 
a 




V3 


> 
3 


a 

T3 

2 


+ 


Experiment 


Inguinal 


Retro-peritoneal 


B 


or 



le. 

Sputum in 
corked and 
parafPned 
white glass 
bottles 
In thermostat 


33 

100 

"5 


40 
40 

42 


Killed 
Killed 
Killed 


Enlarged 

Caseated 

Not enlarged 

Not enlarged 


Enlarged 

Caseated 

Not enlarged 

Not enlarged 


-h 



















+ 





226 



NATIONAL ASSOCIATION FOR THE STUDY 



III 



Conditions 


3 


DEATH 


RESULTS OF AUTOPSY 


Result 






GLANDS 










+ 


of 


« 


Cause 






a 




M 


or 








in 





Experiment 




|l 




Inguinal 


Retro-peritoneal 




^ 
^ 


V 


> 


a 






+ 


II a. 


1 08 


S.3 


Killed 


Enlarged 


Enlarged 


+ 




















Caseated 


Caseated 












+ 


Sputum in 

white glass 

bottles 

stoppered with 


141 

157 


38 
42 


Killed 
Killed 


Enlarged 
Caseated 
Enlarged 
Caseated 


Enlarged 
Enlarged 


+ 
+ 








+ 










+ 


cotton 
Dark moist 


172 


40 


Killed 


Not enlarged 


Not enlarged 




















box 


190 


43 


Killed 


Not enlarged 


Not enlarged 






















61 


76 


Killed 


Enlarged 


Enlarged 


+ 














+ 


lib. 








Caseated 


Caseated 














Sputum in 

white glass 

bottles 


100 


61 


Killed 


Enlarged 




+ 





+ 








+ 








Caseated 


Enlarged 














stoppered with 

cotton 

Dark closet 


141 


32 


Killed 


Not enlarged 


Not enlarged 




















160 


40 


Killed 


Not enlarged 


Not enlarged O 

















lie. 


.3.3 


40 


Killed 


Enlarged 


Enlarged 


+ 





+ 








+ 


white glass 
bottles 








Caseated 
















109 


31 


Killed 


Not enlarged 


Not enlarged 

















0* 


stoppered with 
























Diffuse light 


132 


30 


Killed 


Not enlarged 


Not enlarged 




















ordinary room 

























IV 



Conditions 
of 


03 
u 0. 

H"o 


DEATH 


RESULTS OF AUTOPSY 




1^ 


Cause 


GLANDS 


3 


g 

■3. 


> 

2 


u 

5 


+ 


Experiment 


Inguinal 


Retro-peritoneal 


E 


or 



lid. 

Sputum in 
white glass 

bottles 

stoppered 

with cotton 

In thermostat 


21" 
lOI 
132 


42 

17 
46 
40 


Killed 

Undetermined 

Killed 

Killed 


Enlarged Enlarged 
Caseated 
Not enlarged Not enlarged 

Not enlarged Not enlarged 

Not enlarged Not enlarged 


+ 















+ 


















+ 
0* 





AND PREVENTION OF TUBERCULOSIS 



227 





S^ 




DEATH 


RESULTS OF AUTOPSY 




Conditions 
of 


oQ 










0. 


I1 

a a 

>-J 




GLANDS 










+ 




03 


ij 


Cause 






£ 


m 


a 




>, 


or 


Experiment 


V 0. 


&•■« 




Inguinal 


Retro- peritoneal 


S 

s 


g" 


^ 


>- 


a 







H"o 


Q"' 








s 


c& 


iJ 


)^ 




Ilia. 


108 


49 


Killed 


Not enlarged 


Not enlarged 

















0* 


Sputum in 
























sand 

Moist dark 

box 


171 


42 


Killed 


Not enlarged 


Not enlarged 




















III b. 


62 


78 


Killed 


One slightly Not enlarged 




















Sputum in 








enlarged j 














Dark closet 


108 


49 


Killed 


Not enlarged; Not enlarged 






















77 


'>^ 


Killed 


Enlarged 


Enlarged 


+ 





+ 








+ 


IIIc. 








Caseated 


Caseated 














Sputum in 


123 


21 


Killed 


Enlarged Not enlarged 


+ 














+ 


moist sand 








Caseated 
















Diffuse light 


132 


17 


Undetermined 


Slightly 


Not enlarged 




















ordinary room 


148 


40 


Killed 


enlarged 
Not enlarged 


Not enlarged 





















VI 



Conditions 
of 


f. 

OS 

u a. 


DEATH 


RESULTS OF AUTOPSY 




Days after 
injection 


» 


GLANDS 


e 


s 

■ft 


3 


V 


•0 


+ 


Experiment 


Inguinal 


Retro-peritoneal 


i 

E 


or 



Hid. 

Sputum in 

dry sand 

Diffuse light 

ordinary room 


30 
70 


76 

39 


Killed 
Killed 


Enlarged 

Caseated 

Not enlarged 


Enlarged 
Not enlarged 


+ 




















+ 



Ille. 

Sputum in 

dry sand 

In thermostat 


30 


79 


Killed 


Not enlarged 


Not enlarged 











6 





0* 


Illf. 

Sputum in 

moist sand 

in sealed 

bottle 

In thermostat 


62 


47 


Killed 


Not enlarged 


Not enlarged 

















o« 



228 



NATIONAL ASSOCIATION FOR THE STUDY 



VII 





?^ 




DEATH 


RESULTS OF AUTOPSY 




Conditions 


SO 


























of 


Si 


«s 




GLANDS 










+ 




03 


9, 


Cause 








m 


a 




>> 


or 


Experiment 


B^ 


^■« 




Inguinal 


Retro-peritoneal 


n 

E 


a 


J) 


s: 


T3 






H-^ 


Q 








J3 


en 


J 


!^ 




IV a. 


31 


99 


Killed 


Enlarged 


Enlarged 


+ 


+ 


+ 


+ 





+ 








Caseated 


Caseated 














Sputum on 
handkerchief 


70 


39 


Killed 


Enlarged 
Caseated 


Enlarged 


+ 





+ 








+ 


folded 


IIO 


35 


Killed 


Not enlarged 


Not enlarged 






















"5 


40 


Killed 


Not enlarged 


Not enlarged 




















IV b. 


39 


91 


Killed 


Enlarged 


Enlarged 


+ 


+ 


+ 


+ 





+ 


Sputum 








Caseated 


Caseated 














on 


70 


39 


Killed 


Not enlarged 


Not enlarged 






















88 


38 


Killed 


Not enlarged 


Not enlarged 






















39 


67 


Killed 


Enlarged 


Enlarged 


+ 


0000 


+ 


IV c. 








Caseated 










Sputum 


70 


60 


Killed 


Enlarged 


Enlarged 


+ 





+ o]o 


+ 


on 








Caseated 


Caseated 












wood 


no 


36 


Killed 


Not enlarged Not enlarged 



















130 


36 


Killed 


Not enlarged Not enlarged 


















VIII 





2S. 




DEATH 


RESULTS OF AUTOPSY 




Conditions 
of 


oP 








Result 


a 

>< a 

03 

V P. 


1i 2 


Cause 


GLANDS 


Lungs 
Spleen 
Liver 


a 
•0 


+ 


Experiment 


Inguinal 


Retro-peritoneal 


1 
E 


or 



IV d. 

Sputum on 

woolen 


39 

70 


67 
60 


Killed 
Killed 


Enlarged 
Caseated 
Enlarged 
Caseated 


Enlarged 
Enlarged 


+ 
+ 








+ 




+ 






+ 
+ 


blanket 


no 


51 


Killed 


Not enlarged 


Not enlarged 




















folded 


131 


42 


Killed 


Not enlarged 


Not enlarged 













































AND PREVENTION OF TUBERCULOSIS 
IX 



229 





Sl 




DEATH 


RESULTS OF AUTOPSY 




Conditions 
of 


§Q 








H.esult 


1 - 
03 




Cause 


GLANDS 




a 




>< 


+ 








S 


or 


Experiment 




Q 




Inguinal 


Retro-peritoneal 




Ml 

C 


Si 


> 
3 


1 





V- 


31 


47 


Killed 


Enlarged 


Enlarged 


+!o 











+ 


Sputum in 








Caseated 
















open white 


110 


38 


Killed 


Enlarged 


Enlarged 


+ 





+ 








+ 


glass bottles, 








Caseated 
















outdoors, 


132 


38 


Killed 


Not enlarged 


Not enlarged 




















winter months 


























164 


40 


Killed 


Not enlarged 


Not enlarged 




















VI . 


22 


40 


Killed 


Enlarged 


Enlarged 


+ 





+ 








+ 


Sputum in 
corked white 








Caseated 
















glass bottles 


102 


13 


Undetermined 


Not enlarged 


Not enlarged 

















0* 


buried in 
























ground 
























VII. 


102 


29 


Killed 


Enlarged 


Slightly 


+ 





+ 








+ 


Sputum 








Caseated 


enlarged 
















139 


14 


Undetermined 


Not enlarged 


Not enlarged 




















in blocks 








Slightly 
















of ice 


153 


42 


Killed 


enlarged 


Not enlarged 





















* Results were negative in the following instances : 

With the sputum in glass bottles stoppered with cotton, placed in the diffuse 
light of an ordinary room (11. c) the pigs inoculated at the end of 88 and 100 
days died of unknown cause a few days after the injection. 

With the sputum in glass bottles stoppered with cotton, placed in the ther- 
mostat (II. d) no pig was inoculated between 21 days and loi days, so that 
experiment was of no use as a comparison with the other specimens of that set. 

None of the results with the sputum in sand (III.) was entirely satisfactory, 
due to the death of many pigs from septic infection a few days after inoculation. 

The results were negative in the case of the sputum buried (VI.). The 
pig inoculated after 102 days died at the end of two weeks with no sign of tuber- 
culosis. This inoculation could not be repeated, as the specimen was destroyed 
by mistake. 

Summary 

(LA) The tubercle bacilli in the sputum in paraffined bottles 
placed in a dark, moist box, were alive and produced a tuberculous 
lesion in a guinea-pig at the end of 170 days. No tuberculous lesion 
was produced after 188 days. 

(I. B) With the sputum in paraffined bottles placed in a dark 
closet, a lesion resulted after 160 days but not after 188 days. 

(II. A) With the sputum in bottles stoppered with cotton, placed 
in a dark, moist box, a lesion resulted after 157 days, but not after 
172 days. 



230 NAT. ASS N FOR STUDY AND PREV. OF TUBERCULOSIS 

(I. C) With the sputum in paraffined bottles, placed in the dif- 
fuse light of an ordinary room, a lesion resulted after 124 days but 
not after 175 days. 

(VII.) With the sputum in ice a lesion resulted after 102 days 
but not after 153 days. 

(III. C) With the sputum in sand, in a moist, light place, a lesion 
resulted after 123 days but not after 148 days. 

(II. B) With the sputum in bottles stoppered with cotton, in a 
dark closet, a lesion resulted after 100 days but not after 141 days. 

(V.) With the sputum in open bottles, placed out of doors in the 
winter months, a lesion resulted after no days but not after 132 days. 

(IV. A) With the sputum in a handkerchief, a lesion resulted 
after 70 days but not after no days. 

(IV. D) With the sputum in a woolen blanket, a lesion resulted 
after 70 days but not after no days. 

(IV. C) With the sputum on wood, a lesion resulted after 70 
days, but not after no days. 

(I. E) With the sputum in paraffined bottles, in the thermostat, 
a lesion resulted after 33 days, but not after 100 days. 

(IV. B) With the sputum on carpet, a lesion resulted after 39 
days but not after 70 days. 

(III. D) With the sputum in sand, in a dry, light place, a lesion 
resulted after 30 days but not after 70 days. 

(I. D) With the sputum exposed to direct sun rays, a lesion 
resulted after one hour, but not after seven hours. 

It appears that the conditions most conducive to the prolonged 
life of the tubercle bacillus in sputum are darkness and moisture. In 
our experiment, the bacilli under these conditions were alive at the 
end of five and a half months. Dryness hastens their destruction. A 
temperature of about 37 degrees C. is less favorable for them than 
ordinary room temperature. A temperature near the freezing point 
is less favorable for them than ordinary room temperature. The direct 
sun rays kill them in a few hours. 

My acknowledgments are due to Dr. E. L. Trudeau for the op- 
portunity to try this experiment, to Dr. Lawrason Brown for sug- 
gesting it, and to Mr. Edgar J. Higgins and Dr. A. M. Forster for 
their kindly assistance. 



STUDIES IN MIXED INFECTION IN TUBERCULOSIS 

A PRELIMINARY REPORT 

By Mazyck p. Ravenel, M. D., and J. Willoughby Irwin, M. D. 

Philadelphia 
(From the Laboratory of the Henry Phipps Institute) 



It has been asserted by many investigators of mixed infection in 
tuberculosis, that the flora of pulmonary tubercular cavities varies in 
direct proportion to the purity of the atmosphere in which the patient 
lives. For instance, mixed infection in tuberculosis is much less com- 
mon in a locality that is high, the air dry, and when the invalids live 
mostly out of doors, while in cities mixed infection is found in cases 
only slightly removed from the stage of infiltration, and in all ad- 
vanced cases. This is particularly so in the cases that we have to deal 
with. It is with the fact in mind that we are presenting to you this 
preliminary paper upon the subject of mixed infection. The class of 
people that present themselves at the Dispensary of the Phipps In- 
stitute and enter the hospital are the destitute poor. The circum- 
stances under which these people exist would seem to expose them to 
a variety of mixed infections. 

We have approached this subject along two lines. First, routine 
examination after death of the lungs, kidneys, liver and spleen, and 
any organ or part of the cadaver that would appear to be of special 
interest. Second, examination of washed sputum during life. 

(i) The average time between death and autopsy was 12 hours. 
The method of conducting the investigation was as follows : 

The surface of the kidney, liver and spleen and other organs was 
seared with a hot flat instrument, breaking the centre of the seared 
part with the same instrument, and then a stout platinum loop was 
introduced through the opening into the organ, the loop having been 
previously passed through a flame. The contents of the loop were then 
smeared over slants of glycerin agar-agar. The examination of the 

231 



232 NATIONAL ASSOCIATION FOR THE STUDY 

cavities was made by introducing the sterile platinum loop at once on 
section of the lung. At all times the utmost precaution was taken 
to prevent contamination from outside. The same process was used 
in examination of other organs. Of the 36 cases examined 3 were 
sterile throughout. 

Lung Cavities. — The following bacteria were found and recog- 
nized by the usual methods: Streptococcus, Staphylococcus pyogenes 
aureus, and albus ; Pneumococcus ; B. Pyocyanus ; B. Coli communis ; 
B. Lactis aerogenes; B. Diphtheriae; Sarcinae and Yeasts; also several 
unidentified bacteria. 

36 cavities were examined with the following results : 

The Streptococcus was found 23 times in 33 cases. 

The Staphylococcus pyogenes albus 19 times 

The Staphylococcus pyogenes aureus 11 times 

The Pneumococcus 4 times 

The B. Pyocyanus i time 

The B. Coli communis 20 times 

The B. Lactis aerogenes 3 times 

The B. Diphtheriae 5 times 

Sarcinae 4 times 

Yeasts 9 times 

Spirillum i time 

Small Diplococcus (unidentified) 2 times 

According to cases the following were found in the lung cavities : 

Case I — Staphylococcus pyogenes albus. 

Case 2 — Streptococcus, Staphylococcus pyogenes albus, Staphylococcus 
pyogenes aureus, Bacillus Diphtheriae. 

Case 3 — Staphylococcus pyogenes albus, Sarcinae, Yeast, unidentified 
bacillus. 

Case 4 — Staphylococcus pyogenes albus, Staphylococcus aureus. Bacillus 
Diphtheriae, Yeast. 

Case s — Staphylococcus pyogenes albus, unidentified bacillus. 

Case 6 — Staphylococcus pyogenes albus, Streptococcus, Yeast. 

Case 7 — Streptococcus, Yeast, B. Coli communis. 

Case 8 — Staphylococcus pyogenes albus, Staphylococcus pyogenes aureus, 
Yeast, Colon, unidentified bacillus. 

Case 9 — Staphylococcus pyogenes albus, Streptococcus, B. Coli communis. 

Case 10 — Streptococcus, B. Coli communis. 

Case II — Streptococcus, B. Coli communis. 

Case 12 — Staphylococcus pyogenes aureus. Streptococcus, unidentified 
bacillus. 

Case 13 — Staphylococcus pyogenes albus. Staphylococcus pyogenes aureus, 
B. Coli communis, B. Pyocyanus, Spirillum (unidentified). 

Case 14 — Staphylococcus pyogenes albus. Streptococcus, unidentified 
bacillus. 



AND PREVENTION OF TUBERCULOSIS 233 

Case 15 — Staphylococcus pyogenes albus, Streptococcus, unidentified 
bacillus. 

Case 16 — Streptococcus, B. Coli communis, Pneumococcus. 

Case 17 — B. Diphtherise, B. Coli communis. 

Case 18 — Streptococcus, B. Coli communis. 

Case 19 — Staphylococcus pyogenes albus, B. Coli communis, Pneumococcus, 
Small diplococcus (unidentified). 

Case 20 — Staphylococcus pyogenes albus, Staphylococcus pyogenes aureus, 
Streptococcus, Sarcinae, B. Coli communis. 

Case 21 — Sterile. 

Case 22 — Staphylococcus pyogenes albus, B. Diphtheriae, Yeast, B. Coli 
communis. 

Case 23 — Staphylococcus pyogenes albus. Streptococcus, B. Coli communis. 

Case 24 — Staphylococcus pyogenes albus, Staphylococcus pyogenes aureus, 
Streptococcus, B. Coli communis. 

Case 25 — Staphylococcus pyogenes aureus. Streptococcus, B. Coli communis. 

Case 26 — Staphylococcus pyogenes albus. Streptococcus, Sarcinae. 

Case 27 — Staphylococcus pyogenes albus, Streptococcus, Sarinae, Yeast, 
B. Lactis aerogenes. 

Case 28 — Staphylococcus pyogenes aureus. Streptococcus, B. Coli communis. 

Case 29 — B. Lactis aerogenes. 

Case 30 — Staphylococcus pyogenes albus, Streptococcus, Diphtheriae, 
Yeast, B. Coli communis. 

Case 31 — Staphylococcus pyogenes aureus. Streptococcus, Yeast, B. Coli, 
communis. 

Case 32 — Sterile. 

Case 33 — Staphylococcus pyogenes aureus. Streptococcus, B. Coli communis. 

Case 34 — Sterile. 

Case 35 — Streptococcus, Pneumococcus. 

Case 36 — Streptococcus, B. Lactis aerogenes. 

Kidney. — From the kidney the following organisms were is- 
olated: Staphylococcus pyogenes albus, Streptococcus, Pneumococcus, 
Typhoid, Diphtheria, B. Coli communis and B. Lactis aerogenes, B. 
Pyocyanus. Cultures were obtained in 19 out of 36 cases examined, 
as follows: 

The Staphylococcus pyogenes albus 4 times 

The B. Coli communis 12 times 

The Streptococcus 8 times 

The Pneumococcus 2 times 

The Typhoid i time 

The B. Diphtheriae I time 

The B. Lactis aerogenes i time 

The B. Pyocyanus i time 

Unidentified bacteria i time 

Unidentified diplococcus 2 times 

According to cases the following were found in the kidney : 

Case 6 — Staphylococcus pyogenes albus. 

Case 7 — Staphylococcus pyogenes albus, B. Coli communis. 



234 NATIONAL ASSOCIATION FOR THE STUDY 

Case 8 — Staphylococcus pyogenes albus, Streptococcus. 
Case 9 — B. Coli communis, Streptococcus, unidentified bacteria. 
Case 10 — B. Coli communis, Streptococcus. 

Case 12 — Staphylococcus pyogenes albus, Streptococcus, B. Coli communis. 
Case 13 — B. Coli communis. Streptococcus, B. Pyocyanus, 
Case 18 — B. Coli communis. 

Case 19 — B. Coli communis, Pneumococcus, Small diplococcus (uniden- 
tified). 

Case 20 — Typhoid, Small diplococcus (unidentified). 

Case 23 — B. Coli communis. 

Case 24 — B. Coli communis. 

Case 25 — Streptococcus. 

Case 26 — B. Lactis asrogenes. 

Case 27 — Pneumococcus, Streptococcus. 

Case 28 — B. Coli communis. Streptococcus. 

Case 31 — B. Coli communis. 

Case 33 — B, Coli communis. 

Case 35 — B. Diphtheriae. 

Liver. — From the liver the following bacteria were isolated : 
Streptococcus, Pyocyanus, B. Lactis serogenes, B. Coli communis, 
Staphylococcus pyogenes albus and aureus, Pneumococcus and Clad- 
othrix dichotoma. 

Cultures were obtained in 12 out of 36 cases examined, as follows: 

The Streptococcus i time 

The Pyocyanus i time 

The B. Lactis serogenes : . . 2 times 

The B. Coli communis 6 times 

The Staphylococcus pyogenes albus i time 

The Staphylococcus pyogenes aureus i time 

The Pneumococcus i time 

The Cladothrix Dichotoma i time 

Unidentified bacilli ♦ . . 3 times 

Unidentified diplococcus i time 

According to cases the following were found: 

Case 9 — B. Coli communis, unidentified bacillus. 

Case ID — B. Coli communis, Pyocyanus. 

Case 3 — Staphylococcus pyogenes albus. Staphylococcus pyogenes aureus. 

Case 19 — Pneumococcus. 

Case 24 — 2 unidentified bacilli, i small diplococcus (unidentified). 

Case 25 — Streptococcus, B. Coli communis. 

Case 27 — B. Lactis serogenes. 

Case 29 — B. Lactis aerogenes. 

Case 30 — B. Coli communis. 

Case 31 — B. Coli communis. 

Case 32 — B. Coli communis. 

Case 33 — Cladothrix dichotoma. 



AND PREVENTION OF TUBERCULOSIS 235 

Spleen. — Examination of spleen showed infection in 8 out of 
36 cases. The following bacteria were identified: Streptococcus, 
Staphylococcus pyogenes aureus and albus, Sarcinae, B. Coli com- 
munis and Cladothrix dichotoma, also unidentified bacteria. 

The Staphylococcus was found 4 times 

The Staphylococcus pyogenes albus i time 

The Staphylococcus pyogenes aureus i time 

The Sarcinae i time 

The B. Coli communis 2 times 

The Cladothrix dichotoma i time 

Unidentified bacillus 3 times 

As found in the cases examined: 

Case 9 — Streptococcus. 

Case 12 — B. Coli communis. 

Case 13 — Staphylococcus pyogenes albus. Staphylococcus pyogenes aureus. 

Case 16 — Cladothrix dichotoma. 

Case 24 — B. Coli communis, Sarcinae, 3 unidentified bacilli. 

Case 25 — Streptococcus. 

Case 28 — Streptococcus. 

Case 34 — Streptococcus. 

Other examinations made were as follows: 

Case No. 6 — Bronchial gland, Negative. 

Case No. 7 — Bronchial gland. Negative. 

Case No. 9 — Bronchial gland, Streptococcus, B. Coli communis. 

Case No. 12 — Empyema, Streptococcus, Staphylococcus pyogenes 

aureus, B. Coli communis. 

Case No. 15 — Vermiform appen- Streptococcus, B. Coli communis, 
dix, 

Case No. 16 — Pleural Cavity, Streptococcus, Spirillum, B. Coli com- 

munis, Pyocyanus, unidentified ba- 
cillus. 

Case No. 18 — Cyst, Negative. 

Case No. 19 — Pneumothorax, B. Coli cemmunis, Pneumococcus. 

scraped side and fluid, 

Case No. 21 — Pleural fluid. Tuberculosis. 

^ -T T. !-• « 1 J Streptococcus, B. Coli communis. 

Case No. 23 - Bronchial gland, staphylococcus pyogenes albus. 

Case No. 23 — Heart and Pan- Negative, 
creas. 

Of the 33 cases that showed mixed infection of the lungs, 23 gave 
an infection of one or more organs examined. 

The organisms which have been, put down in the tables as being 
unidentified have all been inoculated into animals, and in no case found 
to be pathogenic. The cultural characteristics will be given in a later 



236 NATIONAL ASSOCIATION FOR THE STUDY 

paper. As far as we have been able to make out, they have not in- 
fluenced the course of the disease. 

We have been somewhat surprised at the number of times in 
which the diphtheria bacillus has been found. This organism has been 
diagnosticated by its cultural and morphological peculiarities; and we 
have been, in every case, unable to differentiate it from the typical 
Klebs-Loeffler bacillus. In no case, however, has the organism proved 
pathogenic for guinea-pigs, and in only one case has it apparently had 
any effect on the clinical history. In case No. 4, Landry's Paralysis 
developed. We are unable, of course, to assert positively that this 
was due to the Klebs-Loeffler bacillus. 

One of the most interesting of our findings has been that of the 
typhoid bacillus in the kidney of Case No. 20. This culture was di- 
agnosticated by the usual cultural method and by the agglutination 
test, and was typical in every respect. It agglutinated at i-ioo in 30 
minutes. The patient from whom it was obtained gave no history 
of ever having had typhoid fever, so that we have been unable to trace 
the origin of it. 

(2) The second part of our investigation which consisted of the 
examination of washed sputum was carried out after the plan sug- 
gested by Kitasato. Twenty-two cases were examined and the fol- 
lowing bacteria were isolated : 

The Streptococcus 22 times 

The Staphylococcus pyogenes albus 9 times 

The Staphylococcus pyogenes aureus 11 times 

The Coli communis 4 times 

The Diphtherias 2 times 

The SubtilHs 3 times 

The Pneumococcus 9 times 

The Sarcinae 17 times 

Unidentified bacilli 8 times 

Small Diplococcus (unidentified) i time 

The Cladothrix dichotoma 2 times 

Yeasts 5 times 

Two cases showing marked mixed infection were repeatedly 
examined over a period of two months, to observe the persistency of 
bacteria, and to determine if possible a relation between the bacteria 
found and the symptoms manifested. It was interesting to note that 
the same species were constantly found, but their effect on the clinical 
symptoms could not be determined. Probably further investigation 



AND PREVENTION OF TUBERCULOSIS 237 

along this line will be of value, and it is our intention to carry it for- 
ward hoping to arrive at some definite conclusion upon the subject. 

The two cases thus examined gave the following results over a 
period of two months: 

Case I — Streptococcus 8 times 

Staphylococcus pyogenes albus . . . , 2 times 

Staphylococcus pyogenes aureus ... 5 times 

Sarcinae 8 times 

Unidentified bacilli 3 times 

Cladothrix dichotoma i time 

According to the eight examinations they were as follows: 

1st examination — Streptococcus and Sarcinae. 

2nd examination — Streptococcus and Sarcinae, 

3rd examination — Streptococcus, Staphylococcus pyogenes aureus, Sar- 
cinae and unidentified bacillus. 

4th examination — Streptococcus, Staphylococcus pyogenes aureus and 
Sarcinae. 

5th examination — Streptococcus, Staphylococcus pyogenes aureas and 
Sarcinae. 

6th examination — Streptococcus, Staphylococcus pyogenes albus. Staphy- 
lococcus pyogenes aureus, Sarcinae, Cladothrix dicho- 
toma and unidentified bacillus. 

7th examination — Streptococcus, Staphylococcus pyogenes aureus, Sar- 
cinae and unidentified bacillus. 

8th examination — Streptococcus, Staphylococcus pyogenes albus, and Sar- 
cinae. 

Case 2 over the same period of time gave: 

The Streptococcus 8 times 

The Staphylococcus pyogenes albus 5 times 

The Staphylococcus pyogenes aureus S times 

The Pyocyanus I time 

Sarcinae 8 times 

Unidentified bacilli 3 times 

According to the eight examinations they were as follows : 

1st examination — Streptococcus, Staphylococcus pyogenes aureus and Sar- 
cinae. 

2nd examination — Streptococcus, Staphylococcus pyogenes albus and Sar- 
cinae. 

3rd examination — Streptococcus, Staphylococcus pyogenes albus. Staphy- 
lococcus pyogenes aureus and Sarcinae. 

4th examination — Streptococcus, Staphylococcus pyogenes albus, Staphy- 
lococcus pyogenes aureus, Pyocyanus and Sarcinae. 

Sth examination — Streptococcus and Sarcinae. 

6th examination — Streptococcus, Staphylococcus pyogenes aureus, Sar- 
cinae and unidentified bacillus. 



238 NAT. ASS'N for study AND PREV. OF TUBERCULOSIS 

7th examination — Streptococcus, Staphylococcus pyogenes aureus, Sar- 

cinae and unidentified bacillus. 
8th examination — Streptococcus, Staphylococcus pyogenes albus, Sarcinx 

and unidentified bacillus. 

Our work has not been completed, and we are not yet in a po- 
sition to draw conclusions from it. The examination of washed sputum 
especially, will require much more study. 

The results obtained up to the present time are offered therefore 
without comment as a contribution to one of the perplexing problems 
of tuberculosis. Every case which has come to autopsy has been 
carefully examined histologically, and the result will be embodied in 
a future paper. 



THE THYROID IN TUBERCULOSIS 

A PRELIMINARY STUDY 

By William B. Stanton, M. D. 
Philadelphia 



The observations now reported are very incomplete. There is 
very little literature upon the subject and my own study has been 
interrupted by some accidents which delayed the work. This report 
may serve to direct attention to some facts not generally considered 
by writers upon tuberculosis. 

Early pathologists looked upon the thyroid gland as exempt from 
invasion by the tubercle bacillus. Rokitanski in 1861 stated that tuber- 
culosis of the thyroid never occurred and in 1865 Virchow placed it 
as an organ least often affected by tuberculosis. Later Lebert, Cohen- 
heim and others established the fact that in general miliary tuber- 
culosis the thyroid usually showed tubercles. Chia'ri, and later on 
Weigert demonstrated that tubercles of the thyroid could be found in 
a fair proportion of cases of chronic tuberculosis — the former found 
thyroid involvement in four out of 96 and the latter in 6 out of 50. 
These statistics are the ones usually quoted by writers upon the subject. 

The thyroid affection is practically always secondary. Of the 
cases of primary thyroid tuberculosis reported that of Bruns and 
Baumgarten seems most trustworthy. In this case no bacilli could 
be found in the sections. It is of course open to the objection that it 
may have been secondary to an undiscovered lesion elsewhere. 

Two forms of involvement are recorded. The least frequent 
being the occurrence of nodules throughout the gland attended with 
increase in size and possible symptoms from compression. Bruns col- 
lected 6 cases besides his own. Miliary tubercles are the most fre- 
quent finding. The organ is not enlarged as a rule. According to 
Moebius these tubercles present the ordinary characteristics of tu- 
bercles in other organs. They arise in the interstitial connective tissue 

239 



240 NATIONAL ASSOCIATION FOR THE STUDY 

separating the follicles. Attention is called to the fact that very few 
bacilli are present in the lesions. 

I have been unable to find any statements regarding the effect 
produced upon the thyroid function by the tuberculous involvement. 
Modern physiologists look upon the gland as of great importance in 
the maintenance of life and it is highly improbable that it could be 
diseased without producing some clinical manifestations. 

At the present time we recognize two forms of disease as the 
result of interference with the function of the thyroid. First, myxe- 
dema or cretinism which follows upon insufficiency of the thyroid; 
and second, Graves' disease or exophthalmic goitre in which there is 
an increased thyroid activity and perhaps also, as stated by Moebius, 
an alteration in the character of the secretion. Manifestations greatly 
resembling the signs of Graves' disease can be brought about by the 
administration of large doses of thyroid extract. These facts justify 
the belief that disease of the thyroid can and does produce definite 
symptoms. 

Those due to thyroid insufficiency are so well known that they 
need not be repeated and besides I have not noted any such in my cases 
and they do not apply in the present instance. Those due to increased 
(and possibly altered activity) are: Tachycardia and palpitation; 
exophthalmus and the sign of Stellwag, v. Graefe and Moebius either 
alone or combined; tremor and other manifestations; goitre or en- 
largement of the thyroid usually slight; gastro-intestinal disorders 
and especially diarrhea; emaciation, pallor, more or less tempera- 
ture, tendency to sweating. 

The finding of several of these symptoms in quite a large number 
of cases of tuberculosis led to this study of the thyroid with a view 
to discovering whether or not it might be at fault. 

Clinically two groups of cases were noted which seemed to depend 
upon the stage of the tuberculosis. In the earlier stages in women 
there was noted slight thyroid enlargement, rapid pulse up to 120 or 
more with palpitation ; tremor of the hands and other signs of nervous- 
ness, as vague pains, etc. ; emaciation, pallor, tendency to sweating, 
but no eye phenomena. With very few physical signs and only slight 
cough and expectoration and with temporary absence of the bacilli in 
the sputum such cases are difficult to diagnose. The second group is 
found among patients in the last or late stages. Here the striking 
feature is the usually slight exophthalmus but with marked Stellwag, 



AND PREVENTION OF TUBERCULOSIS 24I 

Graefe and Moebius signs ; there is usually tremor and often diarrhea. 
Of this variety I have 5 cases now under observation in the wards of 
the Phipps Institute and the Philadelphia Hospital. 

The cases from which the thyroids were obtained upon which this 
report is based were fortunately not examined clinically for the symp- 
toms here referred to. In each case the thyroid was cut into small 
pieces and first examined macroscopically. In only one was a tubercle 
thus recognized. In the 26 thyroids examined tubercles were found 
in 4 and in three of these the bacilli were demonstrated. No report is 
made upon the general histology of the glands. As serial sections were 
not made, it is probable that the proportion found to contain tubercles 
is much too small. 

The purpose of this paper is to call attention first, to the compara- 
tively frequent occurrence in tuberculosis of symptoms similar to those 
met with in disease of the thyroid gland where there is apparently in- 
creased activity ; and second, to the frequency with which tubercles are 
found in the thyroid gland at autopsy. 



DISCUSSION ON DR. STANTON'S PAPER 

Dr. D. J. McCarthy, Philadelphia: During the past two years 
my attention has been directed to this same series of phenomena. 
Very well developed exophthalmic goitre complicated advanced tuber- 
culosis, and the frequency of the cases seen showed a much larger 
proportion than of the number in which tuberculosis in the thyroid 
gland was present. The symptoms of the thyroid trouble were not 
due to the local action of the gland itself. You have more constantly 
in the early symptoms tremor which does not depend upon weakness. 
You have a condition of tachycardia which is connected in some way 
with the indications. These symptoms from association with enlarged 
thyroid are not the results of the increased secretion of the thyroid, 
but the whole group is due to disturbances of the sympathetic system. 
That you may have exophthalmic goitre with disturbed secretions I 
do not deny, but I am inclined to place some of these cases under the 
head of sympathetic derangement due to the action of the disease. 

Dr. Edward L. Trudeau, Saranac Lake: I have seen some cases 
where the tubercular symptoms and the exophthalmic goitre co-existed. 
In these cases tuberculin might be used. 



242 NAT. ASS'n for study AND PREV. OF TUBERCULOSIS 

Dr. E. R. Baldwin, Saranac Lake: Instead of speaking of the 
toxine of the tubercle bacillus we should speak rather of the physio- 
logical effect of the toxine. The exhaustion of the nervous system 
seems to be the focus of the tubercular poison. The poison of the 
tubercle bacillus is a distinct poison to the ganglion cells of the sympa- 
thetic system and it is interesting to bear this in mind. 

Dr. J. H. Lowman, Cleveland: These remarks are very timely 
and it would be interesting to know whether the co-existence of the 
two diseases shows any relation between them. I had one case where 
the association of the two diseases confused me for a while. The 
symptoms reached their maximum in two weeks and immediately after 
the diagnosis was established the treatment was changed but there was 
no special modification of the symptoms. My case was a second stage 
case in which the goitre symptoms developed. Tachycardia occurring 
in early life may be due to something entirely different. I have seen 
several cases of Graves' symptoms associated with phthisis. 

Dr. M. B. Stanton, Philadelphia: I doubt one's ability to diag- 
nose hypertrophy of the heart in a heart that is overacting. As to the 
frequency of the occurrence of the eye signs and the infrequency of thy- 
roid involvement referred to by Dr. McCarthy, I would remind him 
that in his own paper he stated he had found 6 cases covering this. My 
report covers 65 or 70 cases. I believe by making sterile sections we 
can find many more cases infected than we suspect. In early cases we 
may have a stimulation of the thyroid activity, but later on in the late 
stages where the eye phenomena are marked we then have perhaps lo- 
calized disease of the thyroid and the production of the eye phenomena. 



LANDRY'S PARALYSIS COMPLICATING PUL- 
MONARY TUBERCULOSIS 

By D. J. McCarthy, M. D. 
Philadelphia 



The study of the nervous phenomena of pulmonary tuberculosis 
has given us several different forms of paralysis. These may be 
divided into those due to a disturbance of the central nervous system, 
and those purely peripheral in origin. Of the peripheral group, we 
have 

A. Those due to a parenchymatous neuritis in which the nerve 
fibres become degenerated without the evidence of a true inflam- 
matory process in the nerves. 

B. Inflammatory interstitial neuritis in which all the symptoms 
and pathological manifestations of an acute inflammatory process are 
presented. 

C. A complex group occurring immediately before death in which 
the paralysis at first presents the clinical characteristics of a paren- 
chymatous neuritis, but in which there is a tendency to involvement of 
successive groups of muscles giving an ascending type of paralysis 
and probably due to toxic involvement of both the peripheral nerves 
and spinal cord, 

D. Pressure paralysis usually involving the external peroneal 
nerve as it curves round the head of the fibula and at this point, 
subject to' pressure when the patient remains for a long time in one 
position, resting on the external surface of the leg. 

The paralysis due to involvement of the central nervous system 
may be divided as follows : 

A. Those due to acute inflammatory processes of the meninges, 
such as tuberculous cerebral, or spinal meningitis. 

B. Hemorrhagic encephalitis secondary to meningitis, or inde- 
pendent of it. 

243 



244 NATIONAL ASSOCIATION FOR THE STUDY 

C. Paralysis of cerebral origin secondary to infiltrating or encap- 
sulated tuberculous lesions. 

D. Paralysis of cerebral origin due to localized areas of softening 
secondary to local infiltrating processes of the meninges cutting off 
the cortical circulation. 

E. Paralysis of spinal origin from tuberculous tumors of the 
spinal cord. 

F. Paralysis due to internal, or external pachymeningitis second- 
ary to Pott's disease ; partly infiltrating and partly due to pressure. 

G. Paralysis due to tuberculous myelitis which may be diffuse 
and infiltrating in type, or localized to one or more segments ; second- 
ary to obstruction of the circulation of these segments, by active 
arterial disease. 

H. Paralysis due to wide-spread toxic degeneration of the gan- 
glion cells of the anterior horns of the spinal cord. 

Differentiation of these groups of paralysis depends upon a care- 
ful study of the symptoms presented in the individual case. The scope 
of this paper is too limited to consider the differential diagnosis of all 
these above types of paralysis. It will be necessary, therefore, to limit 
this paper to a consideration of the last group above presented. 

As a type of this group, a case of Landry's paralysis with autopsy 
and microscopic examination of the central nervous system, will be 
presented. Landry's paralysis or acute ascending paralysis was first 
described by Landry in 1859. He described it as a purely motor type 
of paralysis without sensory involvement. The microscopic examina- 
tion at first gave entirely negative results, but with the development of 
finer methods for the study of the degeneration of the nerve cells, 
distinct and typical lesions have been found. These are entirely con- 
fined to the motor cells of the anterior horn and to the motor nuclei of 
the medulla and pons. More or less confusion has been added to this 
subject, by a tendency to consider all types of paralysis which ascend, 
as examples of Landry's paralysis. As a result of this, many cases are 
on record as cases of Landry's paralysis in which there have been 
present lesions of the peripheral nerves, which should have been de- 
scribed as cases of peripheral neuritis ; cases presenting inflammatory 
lesions of the gray and white matter of the spinal cord, evidently cases 
of myelitis. In both groups of cases, symptoms other than those of 
a purely motor type of paralysis were probably present, but over- 
looked. 



AND PREVENTION OF TUBERCULOSIS 245 

The clinical picture of Landry's paralysis is distinctive. The 
paralysis is always purely motor in type without objective disturbance 
of sensation; with retention of bladder and rectal control; with loss 
of reflexes in the distribution of the paralyzed parts; and with re- 
tention of consciousness to the termination of the disease. It is as a 
rule, an afebrile condition, running a rapid course and terminating 
after several days, by involvement of the vital nuclei of the medulla. 
Paralysis is not necessarily always ascending in type, but may begin 
in the arm and descend or ascend to the medulla and terminate fatally. 
The disease is not, however, necessarily a fatal one, and cases some- 
times recover. Of the six cases that have come under my observation, 
only one has recovered. This perhaps is, however, too high a per- 
centage of recovery. The disease is a rare one, even in neurological 
practice, and a case complicating pulmonary tuberculosis becomes, 
therefore, of special interest. The cause of Landry's paralysis has 
never been determined, but in all probability, different etiological fac- 
tors are present in different cases presenting the same clinical picture. 
Landry's opinion that he was dealing with a form of obscure intoxi- 
cation, is still considered worthy of consideration. That a toxic-infec- 
tious process is probably the cause of most cases, is supported by the 
presence of enlargement of the spleen and lymph glands, with hemor- 
rhagic foci in the lungs and intestines, and albuminuria in various 
cases. Baumgarten found an anthrax infection in one case, with the 
presence of anthrax bacilli in the blood and tissues. Curschmann 
recorded a case of typhoid bacilli obtained in pure culture from the 
spinal cord. Eisenlohr found in a case evidently due to mixed infec- 
tion, staphylococci in the central nervous system. Remmlinger reports 
a streptococcus infection in a case; Marinesco found a diplococcus. 
Seitz also found a diplococcus which he identified as the Frankel- 
Weichselbaum diplococcus of cerebrospinal meningitis. 

In the case here reported, the Klebs-Loeffler bacillus was found 
in the lungs as a mixed infection, and from blood cultures. They could 
not be found however, in the fixed sections of the spinal cord. No at- 
tempt was made to separate them from the fresh material. The case 
is as follows: 

Case No. 2957. — Name J. V. S. Age 35. Color, white. Single. An- 
cestry American. Admitted to the service of Dr. Joseph Walsh, Dec. 5, '04. 

Diagnosis: Tuberculosis of the lungs, with cavity formation; Landry's 
paralysis. 



246 NATIONAL ASSOCIATION FOR THE STUDY 

Prognosis: Unfavorable. Entered hospital Dec. 5, '05. Result: Died Feb. 
2, '05. 

Occupation: Salesman; four years outside, solicitor for the press; two 
years outside; clerk in a hotel (six years inside) ; clerk one year; school. 

Exposure to contagion: Mother, who died in 1899. Has one brother, deli- 
cate. Had pleurisy four years ago on the right side. No other diseases. 

Present illness (according to himself) six weeks. According to history 
and examination, four years. First symptoms, according to himself, cold ; accord- 
ing to history and examination, pleurisy four years ago. No hemorrhages and 
no pain. Cough not severe, but more at night. Sputum 54 boxful, color yellow. 
Dyspnoea at night and on exertion. Appetite poor. Does not vomit. Bowels 
inclined to constipation. Chills, occasional after sweating. Night sweats. No 
edema. Height 5 ft. 5 in. 

Weight, highest, 140 eight years ago : ordinary 132 : lowest recent, 98 four 
years ago, after which he went up to 132 and dropped recently to 115. Present 
weight loi^. 

Tongue slightly coated, otherwise normal. Throat slightly red. Pupils 
dilated, left larger. Sluggish to light; distance and convergence normal. 

No evidence of previous tuberculosis, no other abnormalities. General 
appearance pretty good. Not pale, not hectic, not cyanosed. 

Emaciation not present. No depression above clavicles, no winging of the 
scapulae. Expansion apparently pretty good, though only two inches by meas- 
urement. Liver not palpable. Spleen and kidney not palpable. Thyroid normal. 
No tenderness over the appendix. 

Heart, mid-sternum, 3rd rib, 5th interspace and nipple line. 

Aortic 2nd accentuated ; no murmurs. 

Sputum, T. B. positive. Urine, acid, 1025, no albumen, no sugar, no diazo. 

Microscopic, a few red blood corpuscles. 

Examination: Right chest — impairment above and below the clavicle; im- 
pairment to mid-scapula posteriorly with hyperresonance below the angle of the 
scapula ; inspiration slightly roughened ; expiration prolonged everywhere. 
Left — Dullness above and below the clavicle; tympany below to the 2nd inter- 
space Hyperresonance below to the 6th rib, and then movable dullness. Dull- 
ness to the mid-scapula region positive and below the eighth rib. Hyperresonance 
between these areas. Cavernous breathing with whispered pectoriloquy about 
the second rib anteriorly and posteriorly. Moist rales everywhere. 

He improved gradually and began to leave his bed about Christmas. 

His weight increased gradually, and on January 26th, he weighed 114^ lbs. 

Examination made on December 29th, showed the same condition as before. 

Diagnosis at this time was : Infiltration left upper lobe with cavity ; in- 
filtration of upper part of right upper lobe; small effusion at base of left lung. 

Nervous Examination: There is no nervous disease or insanity in the 
family. The patient has no present nervous disease, was educated for college, 
was of hopeful mental attitude, good memory and no delusions. Since admission 
he had slept poorly. On Thursday, January 26th, he complained of numbness 
in the fingers of both hands with some loss of power in the hands and arms 
and at the same time had some difficulty in walking, due to loss of power in 
the legs. On the 29th, there was little numbness, but the loss of power was 
much worse; he could hardly lift his arm and there was marked toe-drop. On 
the 30th, he was unable to lift his leg sufficiently to get out of bed and there 
was a very marked loss of power in both the hands and arms. There is marked 
paralysis in all four extremities. There is some slight muscular action retained 



AND PREVENTION OF TUBERCULOSIS 247 

in the left biceps and deltoid. He complained to-day that his tongue feels heavy, 
that he is unable to articulate properly and that his " tongue feels thick in his 
mouth." The palate and pharyngeal reflexes are normal. Sensation for touch, 
pain and temperature stimuli is preserved over the entire body. There is no 
pain and has been none since the beginning of the trouble. There is no tender- 
ness over the nerve trunks. There is some slight difficulty in deglutition. The 
cranial nerves to objective examination, with the exception of a fibrillary tremor 
and some slowness of action of the tongue, are normal. The pupils are equal 
and react to light and accommodation promptly. The left palpebral fissure is 
narrower than the right. On extreme outward excursion of either eye, jerking, 
nystagmoid movements are observed. 

Reflexes — The plantar reflexes, the tendon Achilles reflexes, the knee 
jerks and the superficial skin reflexes are absent. There is a slight biceps jerk 
on the left side. The other reflexes of the upper extremities are absent. 

On January 30th, the condition remains the same with the exception that 
the patient seems to be weaker and has some difficulty in swallowing both 
solid and liquid food and getting up his expectoration. There is some loss of 
power of movements of the head. January 31st, the condition remains the same. 
There was little change in this condition with the exception of the gradual 
progress of the difficulty in swallowing and occasional choking spells, until 
February sth, when he died from respiratory failure. 

The electrical examination reveals a loss of reaction of the muscles of 
the lower extremities to Faradic current. Muscular reaction to the Galvanic 
current in the muscles below the knee, were distinctly slowed. An CI C > K 
CI C. The muscles of the thigh K CI C > An CI C. This is also true of the 
upper extremities. The course of the nervous symptoms with the absence of 
pain or tenderness through the muscles or nerves, or of other general changes in 
the rest of nervous system, with loss of the reflexes made the diagnosis of Lan- 
dry's paralysis. 

Autopsy: Gross examination of the brain. There was considerable sub- 
arachnoid edema localized to the brain and motor areas. This is a condition 
found in the large majority of cases of tuberculosis. There was a moderate 
grade of internal hydrocephalus. The ventricular fluid was clear. The brain 
and spinal cord were otherwise normal. 

The peripheral nerves were removed and carefully studied after the autop- 
sy, by the fresh osmic acid methed. (The fresh nerves were teased, placed 
in a one percent solution of osmic acid for twenty-four hours, teased in gly- 
cerine so that the individual fibres could be examined.) The following nerves 
were examined : 

The ulnar, median, anterior and posterior tibial, sciatic, vagus, phrenic, 
sympathetic and splanchnic nerves. These nerves were perfectly normal to 
microscopic investigation. The fresh osmic acid method above described, the 
most delicate method for detecting degenerative changes in the peripheral nerves, 
gave entirely negative results in all these nerves. This was most surprising 
in view of the degenerating electrical reaction noted in some of the muscles. 
The spinal cord was studied by the haematoxylin eosin. Van Giesen, iron 
haematoxylin, Weigert, and especially by the Nissl method. Serial sections 
through the medulla and pons were made and stained by these methods. Sec- 
tion.? from the different segments of the spinal cord were also made and studied. 

The white substance of the spinal cord was entirely normal to the sheath 
methods and the usual nuclear stains. There were no changes in the meninges. 



248 NATIONAL ASSOCIATION FOR THE STUDY 

The changes noted by the hsematoxylin eosin method, were confined entirely 
to the gray matter. All the ganglion cells were more or less degenerated and 
present a hyaline pink appearance. Many of them were shriveled and con- 
tracted and only a very few of them presented a nucleus. Many of the cells con- 
tain large quantities of yellow pigment. The blood vessels were normal as were 
also the meninges and the white matter. The central spinal canal is patulous 
even through the lumbar enlargement. The same microscopic picture is seen 
throughout the entire spinal cord and medulla. 

The Van Giesen method presents the same changes as above noted. 

The axis-cylinders within the gray matter of the anterior horn and ex- 
tending into the anterior roots, presented a swollen appearance. The anterior 
roots themselves, however, present no such change. 

Nissl method. Practically all the cells of all the sections examined, taken 
from each segment of the spinal cord, present marked degenerative changes. 
It is exceptional to find a cell approaching the normal condition. The nucleus 
is retained in less than one-fourth the number of cells. In these cells it is dis- 
placed towards the periphery, shrunken in appearance and without its chromatin 
net-work. All of the cells have a swollen vesicular appearance, and those 
showing the most degeneration stain a pale blue without any chromophilic 
elements. In some of the cells a single row of chromophilic elements are 
present at the extreme periphery of the cell. These few cells in which the 
chromophilic elements are retained, are in a condition of pyknosis. The cells 
in the nucleus of the twelfth nerve present the same changes as those seen in 
the spinal cord. The cells in the olivary body present a comparatively slight 
degenerative change. The same may be said of the sensory nuclei. The cells 
of the tenth nucleus and the nucleus ambiguous show marked degeneration, but 
there is a larger portion of the cells approaching the normal type than in the 
twelfth nucleus. The cells of the nucleus of the seventh nerve are practically 
normal with the exception of a few which are in a condition of pyknosis. The 
nuclei above this level show no pathological change. The cells of the cortex 
of the motor and frontal areas are slightly pigmented, but are otherwise nor- 
mal. The cerebral tissues by the other methods, show no pathological change. 

The lesions in this case are therefore entirely confined to the motor 
ganglion cells of the spinal cord and medulla. The peripheral nerves 
were entirely normal. The cerebral cortex was normal. These lesions 
therefore correspond to the clinical picture and establish the clinical 
diagnosis of Landry's paralysis. 

The only diagnosis to be seriously considered in this case is that 
of multiple neuritis. The absence of pain, the absence of tenderness 
along the nerves, the retention of all forms of sensation to a normal 
degree, exclude this diagnosis. An infiltrating lesion high up in the 
spinal chord could produce paralysis of all four extremities, but the re- 
flexes would be increased rather than lost. 

The reflexes following the progress of paralysis, localized the lesion 
to the peripheral neuron, that is, somewhere from the anterior horn 
ganglion cell to the periphery. 



AND PREVENTION OF TUBERCULOSIS 249 

The pathological examination does not establish definitely the 
cause of the cell degeneration. The bacteriological examination (made 
by Drs. Ravenel and Irwin) showed the presence of the diphtheria 
bacillus on glycerine slants. Cultures taken from the lungs showed 
staphylococcus pyogenes aureus and albus, yeast and diphtheria. The 
diphtheria bacillus here obtained was not virulent for guinea-pigs. It 
is possible that any of these factors, or possibly a combination of them 
might, with the tubercle bacillus, furnish the intoxication necessary to 
cause the cell degeneration. It was unfortunate that a culture from 
the spinal fluid was not obtained during the life of the patient. Of the 
organisms noted above in this case, the diphtheria bacillus is by far the 
most potent in its effects upon the nervous tissue. The effect of the 
toxin of this organism on the peripheral nerves and ganglion cells, has 
long since been established, both clinically and experimentally. It is 
probable, therefore, that the mixed infection with this organism was 
the material factor in the production of the nervous symptoms. 



CLINICAL AND CLIMATOLOGICAL 

SECTION 

Chairman 
NORMAN BRIDGE, M. D. 

Los Angeles 

Secretary 
SHERMAN G. BONNEY, M. D. 

Denver 
(In the absence of Dr. Bridge, Dr. Bonney acted as Chairman of the Section) 



IMPALPABLE SPUTUM, AS A USUALLY OVER- 
LOOKED DANGER IN TUBERCULOSIS 

(Read by Title) 

By Norman Bridge, M. D. 
Los Angeles 



The evidence is accumulating that hereditary tendency is much 
less potent in causing tuberculosis than has been believed. Direct in- 
fection regardless of such tendency is much more responsible for it; 
and direct infection is very easy, and extremely common. The infec- 
tion usually invades first the lymphatic nodes of the throat, neck, chest 
or abdomen, where it may remain latent for months or years, to break 
forth in the lungs, meninges, bones, joints, the pleura or the peritoneum, 
by reason of some lowering of the vital powers. In some communities 
probably a third of all the people acquire this sort of infection before 
their fortieth year. 

Von Behring is therefore probably right that pulmonary consump- 
tion is usually a terminal event in a disease that begins in the lymphatics 
long before the lung symptoms appear. There is less reason to think 
him right in assuming that the original infection is chiefly from in- 
fected milk, and by way of the intestinal canal. 

Kitasato has recently shown ^ that in Jap^n the children acquire 
tuberculosis of the abdominal organs rather more frequently, in pro- 
portion to the whole number of cases of the disease, than occurs in 
Europe. And the Japanese children hardly take milk at all ; the amount 
of milk consumed by large urban populations not reaching three tea- 
spoonfuls a day per person. Moreover the only tuberculous cows in 
Japan are a few that have been imported. These facts demonstrate that 
the infection of children through the abdomen must be by bacilli taken 
into the mouth in the inspired air and in substances handled, and then 
swallowed. Some of these bacilli are doubtless gathered upon the 

^American Medicine, Jan. 7th, 1905. 

253 



254 NATIONAL ASSOCIATION FOR THE STUDY 

hands from the floors and ground upon which the children live and 
play. 

Harbitz^ has recently shown, by a series of most careful post 
mortem studies, that more than 48 per cent, of all children dying in the 
public hospital of Christiania had tuberculous lymph nodes, especially 
of the neck and chest. He also appears to have demonstrated that the 
disease began above the diaphragm twice as often as below it. 

It is unjustifiable to assume, as we usually do, that only those 
become infected with tuberculosis who show pronounced symptoms 
within a few months. He who to-day shows evidence of phthisis may 
have acquired the infection years ago. And a supposedly uninfected 
person is not safe for years afterward who has been exposed to an 
atmosphere charged with tubercle bacilli. 

The tangible sputum of consumptives, by becoming dry and pul- 
verized, often contaminates the air and poisons the uninfected. This 
we know of and wage war against. And so a very large proportion of 
consumptives are careful to destroy much of their sputum, and try to 
destroy all of it, and mistakenly think they succeed. 

A source of positive menace to the well is the intangible, minute 
particles of tuberculous sputum ejected by the consumptive with an 
explosive cough, and which falls on clothes, furniture, floors, rugs 
and carpets. The close proximity of every such patient is a positive 
danger to people coming into it. For his activities and those about him 
are constantly pulverizing this sputum and sending it into the air, to 
infect others. Every bodily movement of the patient and every footfall 
near him contributes something to the pulverizing process. This danger 
is more formidable because it is neglected and unthought of. And the 
peril is positive, as shown by numerous experiments upon tuberculous 
patients and other patients with explosive cough, and who have patho- 
genic germs developing in their throats or coming into them from the 
lungs below. The demonstration is absolute and cannot be denied.^ 

Our duty regarding this danger ought not longer to be neglected. 

^ Jr. Infectious Diseases, Vol. II, No. 2, March ist, 1905. 

' Investigations of Boston showing that spray from the mouths of con- 
sumptives, even when not coughing, contained bacilH in sixty per cent of cases 
{Jr. Am. M. Assn., Sept. 14th, 1901) ; of M. Goldin showing that plates held 
in front of the mouths of coughing consumptives showed bacilH in 26 to 60 per 
cent, of cases {Canada Prac. & R., Aug., 1899) ; of Flugge proving the frequent 
ejection of minute droplets of tuberculous sputum in the act of coughing, and 
of De Leon and AHce Hamilton showing that streptococci are projected from 
the mouth by coughing and even by talking {Jr. Am. Med. Assn., Apr., 8th, 1905). 



AND PREVENTION OF TUBERCULOSIS 255 

The most dangerous sputum now, in this somewhat enUghtened day, is 
not the masses spat out in plain sight of everybody, and that are often 
if not usually destroyed. The most dangerous is that which is caught 
on the beards and especially the moustaches of men. The next most 
dangerous is this intangible sputum that is ejected by explosive cough, 
is not seen, and which falls on everything within three or four feet of 
the front of the patient. These two forms are very rarely destroyed, 
and the latter has substantially never received the smallest consideration 
from patient, nurse, or physician. 

A crusade should be started now against this insidious, smokeless 
powder peril of the race. It is possible greatly to reduce the danger 
from it. We are now everywhere agreed that the tangible sputum must 
be destroyed, and we agree as to the means of destruction. We must 
agree on measures for the destruction of the intangible sputum as well, 
for the need is just as real if not as great. Because of the intangibility 
of the poison, as well as of the natural skepticism of lay people and 
doctors, such a crusade will be the most difficult of all. This fact makes 
our duty more plain and pressing. Moreover the necessary preventive 
measures will often involve more attention, carefulness and labor than 
we now bestow on the destruction of tangible sputum. A patient is 
reminded of his duty by the presence of phlegm in his mouth, and finds 
it easy to send it on the way to destruction ; he has no such reminder 
when he is worried by a spiteful cough that he calls dry because it 
brings no perceptible masses into his mouth. To say that every hour, 
day and night, he must remember to hold a shield in the shape of a 
cloth or paper before his face when he coughs, and then destroy the 
shield, is to impose a large tax on his attention and faithfulness. Prob- 
ably few patients are equal to such a task ; with the best of intentions 
they forget and grow careless. 

This measure would probably be effective if it could be carried out. 
But this we can hardly hope for, and so some precautions must be taken 
that do not depend on the self-watchfulness and faithfulness of the 
patient himself. This duty lies first at the door of the physician ; then 
it falls on the attendants of the sick, the friends and nurses ; then on the 
patients themselves. The devices of prevention must be simple and 
effective; they must be relatively inexpensive, they must not impose 
great burdens on the patients or their friends either in labor or mental 
attention. But they will all require attention and faithfulness every day 
of the year. 



256 NATIONAL ASSOCIATION FOR THE STUDY 

The most feasible effective measures (after the removal of beards 
and efforts to have patients hold cloths or paper before their faces when 
they cough) will probably consist of the use of heat, sunlight and 
germicides, for the destruction of the atomized sputum that falls near 
the patients. 

One of the best of measures is an oven with means of providing 
heat regulated to a limit of 212° F. for the sterilization of clothes and 
rugs. Such facilities are not now to be found in hospitals and houses. 
They ought to be provided, and they need not be expensive. The appa- 
ratus might be heated by gas-jets, the intensity of the flame being regu- 
lated by an automatic thermostat. Or a sheet-iron oven could be 
surrounded by a water-jacket whose boiling temperature would easily 
keep the oven heat above the pasteurizing point, and so destroy all tuber- 
cle bacilli. An oven could even be constructed with gas-jets for heat; 
and a little experimenting with a thermometer would soon determine 
how many jets burning at full head would be required to keep the tem- 
perature between 180 and 212° F. 

The outer clothing of the consumptive — his day clothes, his night 
clothes and his bed coverings — ought to be ovened every day, or every 
few days for fifteen minutes. Carpets for the tuberculous ought to be 
tabooed, and all suspicious rugs ought to be subjected regularly to the 
evening process. This would be most satisfactory and successful. 

If garments, bedclothes, and rugs could be subjected to the sun's 
rays a few hours each day all the bacilli would be destroyed. To be 
effective it would be necessary that two sets of clothes be in service 
constantly, one being worn, while the other is exposed to the sun. 
These articles would not need to be placed out of doors to have the 
effect of the sun, provided they could be exposed behind glass ; al- 
though it would be rather better to have them exposed out of doors. 

Several obstacles will always prevent the full benefit of this last 
measure. The sun does not always reach the habitation of the patient ; 
it does not always shine for us even in the daytime. Such things have 
been known as a month of sunless days. Then the care, expense and 
daily attention required, bar it from many of the sick. They have not 
the strength, the sense, or the means to carry out such measures. For 
many of these sick people the greatest benefit of sunlight for disinfec- 
tion of clothes comes of their sitting out of doors for hours each day, 
and thus exposing their outer garments for some time and some days to 
the sun. But this as a preventive measure is quite unreliable, because 



AND PREVENTION OF TUBERCULOSIS 257 

it is not daily, and it is not constant in the length of sun effect even on 
the days when the patients sit out. 

The clothes may be hung every night in a formalin closet, with 
some good effect, perhaps with perfect disinfection. Such a closet 
would need to be tight, that is, free from any even accidental means of 
ventilation ; and it should be constantly charged with the fumes of for- 
maldehyde. If the outer clothing could be kept every night in such an 
atmosphere it would perhaps effectually remove the dangers referred 
to. 

Disadvantages beset this measure too. It is disagreeable. The 
clothes taken out of the closet in the morning smell for some time of 
the pungent drug, and patients dislike it. This difficulty can be re- 
moved effectually if the clothes are hung out of doors a little while after 
leaving the closet and before being used, or if the patient will in the 
morning sit for an hour facing a gentle zephyr. This is what all the 
patients ought to do — but which most of them will not do. The effect 
of the latter device is to waft the bad odor backward and away from the 
face of the patient, and so do away with all annoyance to him, whatever 
his attendants may suffer. 

Even if any or all these measures could be effectually carried out 
for every tuberculous patient, for the disinfection of clothes, hangings, 
and rugs, there would still be great danger from the intangible sputum 
which falls on furniture, floors, walls and utensils. Some means should 
be provided for disinfecting these things with perfect regularity. 

Furniture upholstered with cloth of any kind is decidedly objec- 
tionable ; for it is next to impossible to disinfect it. This is a misfortune, 
for cloth upholstery is very grateful to the body of an emaciated patient. 

A wood chair or lounge covered with many folds of blanketing is 
nearly or quite as comfortable, and the covering can be evened or ex- 
posed to the sun, while the wood surfaces may be treated with various 
disinfecting solutions. One of the best of these is a solution of subli- 
mate, one to two or three thousand, with which the furniture and the 
floors may be wiped occasionally — even the smooth walls of rooms and 
the general woodwork above the floors may be so treated with good 
effect. Carbolic solutions are effective for floors and furniture, but 
they leave an odor that is very disagreeable to some people. Lysol 
solutions would be effective, but they are nearly as offensive as the car- 
bolic acid. The popular chloride solutions, so much in use as disin- 
fectants for closets and privies, are probably incapable of destroying 



258 NAT. ASS'n for study AND PREV. OF TUBERCULOSIS 

tubercle bacilli, as used upon floors and carpets. Soap and water for 
the furniture and floors are always in order and if used frequently 
must do a great deal of good in a prophylactic way. 

The measures that are here proposed are tentative and suggestive. 
Others and perhaps better ones may be proposed by others. My con- 
tention is less for particular methods of reaching the end, than for the 
end itself — and I am sure that the object to be accomplished as here 
set forth is of the highest possible importance. Its neglect so long by 
the profession of medicine has, I believe, worked unspeakable damage 
to the people. 



REPORT OF THE COiMMITTEE ON CLINICAL 
NOMENCLATURE 



Dr. Vincent Y. Bowditch, Boston, Chairman 

Dr. W. H. Bergtold, Denver 

Dr. Lawrason Brown, Saranac Lake 

Dr. Herbert Maxon King, Liberty 

Dr. George W. Norris, Philadelphia 

Dr. John H. Pryor, Ray Brook 



The appended report is made by the Committee on Nomenclature 
appointed by the President of the National Association, after long- 
continued discussion and earnest endeavor to decide upon a scheme 
which shall be of practical use in tabulating cases of pulmonary tuber- 
culosis and in making comparisons of the results of residence in 
different parts of the United States. 

The International Association in Europe has already adopted 
the plan suggested by Turban and in order as far as possible to make 
uniformity of records Turban's plan forms the basis of our own. As 
the former did not appear to be quite comprehensive enough to satisfy 
our needs, the Committee has made some modifications of and additions 
to the original plan. 

The great difficulty of presenting any report which will be satis- 
factory to all will be recognized at once. It should be stated moreover 
that the one presented has been formed only by mutual concession and 
after full discussion on the part of every member of the Committee. 

The plan of dividing the cases into classes of " incipient," " moder- 
ately advanced," etc., is suggested to supplement the divisions I, II, and 
III made by Turban which are anatomical only and do not seem quite 
comprehensive enough in character. 

In presenting the scheme to the Association for approval or other- 
wise the Committee recognized the fact that it is necessarily not perfect, 
but believes it can be used as a working basis and that time alone will 
show whether further modifications are advisable or not. 

259 



26o 



NATIONAL ASSOCIATION FOR THE STUDY 



Translation with some Modifications of Turban's Scheme for a Method 
OF Comparative Statistics for Pulmonary Tuberculosis 

From Tuberculosis, monthly publication of the Central International Bureau for 
the Prevention of Consumption. September, 1904. Johann Ambrosius 
Barth, Leipzig. 

Suggested for use in the National Association, with the addition of the scheme 
offered by the Committee. 

For exact definition see below. 



Period to date from the observation of 
the first clinical symptoms, e.g., stub- 
born coughing, haemoptysis, pleurisy, 
loss of flesh, etc. 

A = favorable. 

X = unfavorable. 

B = unimpaired. 

Y = impaired. 

The pulse is to be registered every morn- 
ing and evening, the patient resting. 

F = Maxima for the day of 101° F. 

f = Maxima for the day from 99° F. to 
101° F. 

t n = normal temperature (mouth) . 

+ = tubercle bacilli present. 

O = tubercle bacilli absent. 

Name of the organ suffering from 
tuberculosis. 

Name of the disease. 

Vide Classification of Results of Treat- 
ment proposed by Committee on 
Nomenclature. 

Definition of the Extent of Disease in Lungs, According to Turban: 

" I. Slight lesion extending at most to the volume of one lobe or two half 
lobes. 

"II. Slight lesion extending further than I., but at most to the volume 
of two lobes ; or severe lesion extending at most to the volume of one lobe. 

"III. All lesions which in extent of the parts affected exceed II. 

" By ' slight lesion ' we understand disseminated centres of disease which 
manifest themselves physically by slight dullness, by harsh, feeble, or broncho- 
vesicular breathing, and by rales. 

" By severe lesion ' we mean cases of consolidation and excavation such as 
betray themselves by marked dullness, by tympanitic sounds, by very feeble 
broncho-vesicular, bronchial, or amphoric breathing, by rales of various kinds. ^ 

" Purely pleuritic dullness, unless marked, is to be left out of account ; if it 
is serious, the pleurisy must be specially mentioned under the head of 'tuber- 
culous complications.' 

"The volume of a single lobe is always regarded as equivalent to the 
volume of two half lobes, etc." 



I. 


Extent of disease in 


I. 




lungs : 


11. 
III. 


2. 


How long consump- 
tive? 


3 months 


3- 


General condition of 


A 




the patient: 


X 


4- 


Digestion : 


B 
Y 


5- 


Pulse : 




6. 


Temperature : 


F 

f 

tn 


7. 


Tubercle bacilli: 


+ 



8. 


Tuberculous compli- 
cations : 


Larynx 


9- 


Other complications: 


— 


10. 


Result of treatment : 


— 



AND PREVENTION OF TUBERCULOSIS 



261 



By the Committee 

Proposed Classification of Cases and Results of Treatment in Pulmonary Tuber- 
culosis, to be Used in Connection with Turban's Scheme 

Progressive: (Unimproved.) All essential symptoms and signs unabated or in- 
creased. 

Improved: Constitutional symptoms lessened or entirely absent; physical signs 
improved or unchanged; cough and expectoration with bacilli usually 
present. 

Arrested: Absence of all constitutional symptoms; expectoration and bacilli may 
or may not be present; physical signs stationary or retrogressive; the fore- 
going conditions to have existed for at least two months.^ 

Apparently Cured: All constitutional symptoms and expectoration with bacilli 
absent for a period of three months; the physical signs to be those of a 
healed lesion. 

Cured: All constitutional symptoms and expectoration with bacilli absent for a 
period of two years under ordinary conditions of life. 

To be used in connection with Turban's scheme of dividing the stages of 
disease into I, II and III. 

Slight initial lesion in the form of infiltration 
limited to the apex or a small part of one lobe. 

No tuberculous complications. Slight or no 
constitutional symptoms (particularly including 
gastric or intestinal disturbances or rapid loss 
j of weight). 

Slight or no elevation of temperature or ac- 
celeration of pulse at any time during the twenty- 
four hours, especially after rest. 

Expectoration usually small in amount or ab- 
sent. 
Tubercle bacilli may be present or absent. 



Incipient {Favorable) 



Moderately Advanced 



Far Advanced 



No marked impairment of function either local 
or constitutional. 

Localized consolidation moderate in extent with 
little or no evidence of destruction of tissue; 

Or disseminated fibroid deposits. 

No serious complications. 

Marked impairment of function, local and con- 
stitutional. 
Localized consolidation intense ; 
Or disseminated areas of softening; 
Or serious complications. 



Acute Miliary Tuberculosis 

* The length of time mentioned is of course somewhat arbitrary, but is 
intended to cover the cases which frequently occur, where the patients leave a 
sanatorium for various reasons, contrary to advice, after a stay of a few weeks, 
although all active symptoms may have ceased completely soon after entrance. 



262 



NATIONAL ASSOCIATION FOR THE STUDY 



U 



^ ^ 






rt 
u 

1 






bb 
C! 




J3 
1 


bb 

C 






+ 









8 


5? 

00 


2s 


8 

i-t 




d 
1 

5 


a> 

i 

1— 1 


T3 
4) 

ft 

s 

'S 

t3 


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0) 

1 



> 


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2oS 




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1— 1 


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1— 1 


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<u 

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tn 

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1 




>< 

C 

g 



AND PREVENTION OF TUBERCULOSIS 263 

DISCUSSION ON THE REPORT OF THE COMMITTEE ON 
CLINICAL NOMENCLATURE 

Dr. John H. Pryor of Ray Brook, N. Y. : Permit me to explain 
very briefly that the sole object to be gained in accepting Turban's 
scheme is, that we shall have secured thereby an International Nomen- 
clature. Turban's scheme has been accepted in England, France and 
Germany and if it is employed here with the modifications suggested, 
we shall be able to understand foreign reports and Continental authori- 
ties will be able to understand us. 

It must be remembered that we advise only the use of Turban's 
scheme as modified, in tabulating individual cases. At the present 
time no definite form is used by different men in different locations 
in reporting their cases, and, we advise employing this scheme for one 
year to secure uniformity. The scheme developed by the Committee 
for the purpose of reporting results is somewhat similar to that con- 
sidered by the Climatological Society two years ago. 

In the opinion of the Committee very radical changes should not 
be made this year and we feel that one year's experience will bring out 
just criticism of a constructive character and promote valuable sugges- 
tions. As to the definitions of the various forms of cases, which you 
will notice on a single sheet, this will apply in a general way to the 
character of the cases in reference to the results of treatment and prog- 
nosis. 

We have simpHfied the definitions and limited them in number to 
three classes : " Incipient or Favorable," and advise the use of the 
word " Favorable " rather than " Incipient," because the term " Incip- 
ient " is apt to be used too much in relation to time. Second, " Moder- 
ately Advanced" and "Far Advanced," and." Miliary Tuberculosis" 
which is placed in a class by itself. We recognize the fact that this 
report should not be made too comprehensive and that by dividing cases 
into classes and giving definitions of each we should have a nomen- 
clature and classification which would be interminable. 

The importance of adopting some classification is only too appar- 
ent, and it seems reasonable to say that this Society can perform no 
more important function this year than to make a step away from the 
chaotic condition which prevails. 

We ask that the report be adopted and employed for one year. 
Before the next meeting suggestions and criticisms could be sent to the 



264 NATIONAL ASSOCIATION FOR THE STUDY 

Chairman of the Committee and there is no doubt that the classification 
could be improved after one year's trial. 

Finally, it must be remembered that Turban's scheme has been 
decidedly modified to meet many objections which would certainly arise 
in this country and that Turban's scheme is associated with definitions 
and a classification, many phases of which have been in use for some 
years in this country. I urge the adoption of the report and hope that 
it will be tried for one year. 

Dr. Alfred Stengel, Philadelphia: This report is based upon 
Turban's scheme as has been said and will be more or less familiar to 
those who are interested in this subject. I think it fulfills two of the 
most important conditions that we have to consider: (i) it gives a 
uniformity of report, which is its principal advantage; (2) it seems 
to me that the Committee has acted wisely in adopting a scheme which 
will be international in character, as it will make our reports valuable 
for their use and theirs for ours. A third point, this scheme is particu- 
larly useful because it will furnish us with some means of gauging the 
results that are reported, the methods of treatment and the actual prog- 
ress that is being made. As to the special part which the Committee 
has added it seems to me that some improvement might be made in the 
future though I should feel like voting for this scheme as presented for 
this year. Some modifications might be made in the part suggested by 
the Committee dealing with the results of treatment. Some such plan 
as this might be adopted : let us say under " arrested," etc., we might 
number them A, B, C, and D. A case might be reported as A — i to 
3 or I to 5. Granting that the case fell within the scope of that classifi- 
cation to the extent that there was absence of all constitutional symp- 
toms, absence of tubercle bacilli, physical signs stationary or retro- 
gressive, the case might then come under C — i to 3. It will neces- 
sarily happen that some cases will not fit exactly into these groups but 
it seems to me that a decimal nomenclature might be a good thing. In 
the multifarious character of clinical cases it follows that no classifica- 
tion can include all cases. If a case for example shows a complete 
arrest of all constitutional symptoms, if there shall be a complete arrest 
of the progress in physical signs, and if bacilli were still occasionally 
present, the case would not be classified under the head of " arrested " 
and yet that condition of things does not exactly correspond to the class 
of cases entitled " improved." Some classification which will bear on 
its face an indication of what kind of improvement has been obtained 



AND PREVENTION OF TUBERCULOSIS 265 

will have to be made as there are some cases which will not exactly fit 
into the scheme as presented to-day. In the meantime we should give 
this scheme a trial as it seems to be a very happy solution of the 
problem. 

Dr. V. C. Vaughan, Ann Harbor: I agree with Dr. Stengel that 
it is the best thing to accept the classification that has been proposed 
by the Committee for the reasons which have been stated, particularly 
as it gives uniformity with European classifications. By this means 
we can understand each other's reports and I shall be highly in favor 
of adopting the report of the Committee. Under " Exudation " I would 
put any cases with any demonstrable lesions in the lungs. There are 
cases where there is no marked infiltration of the lungs, cases where 
there is probably nothing more than two or three slightly swollen glands 
of the neck, with some elevation of temperature, and where if we take 
the temperature we will find the slight elevation only present at a cer- 
tain time of the day. It is desirable that we should recognize, and teach 
the profession to recognize, tuberculosis in its earliest stages. I do not 
like to use the word " cured." How about " quiescent " for so long? 
By that we mean no extension, expectoration or bacilli. 

Dr. DeLancey Rochester, Buffalo: I heartily second what Dr. 
Vaughan has said about the word " cure." The results of autopsies 
show that we are not justified in saying that a case is " cured." A 
patient may seem well, but as to being " cured " that is not so and that 
word should not be used at all by a scientific body. It had better be 
dropped as a part of the classification. As to " arresting," as long as 
bacilli are present a case is not " arrested." 

Dr. G. M. Linthicum, Baltimore : If we remove the word " cured " 
we shall discourage many people who are largely interested in this 
work. It seems to me that these cases are just as much " cured " as 
a case of rheumatism is " cured." The word is extremely important 
and it is very necessary that it should be retained. 

Dr. Robert Reyburn, Washington : What is the history of all post- 
mortem examinations? It is that 90% have had some form of tuber- 
culosis during their lives and for this reason we should retain this 
word " cured." The popular idea of the people is that if a man has 
tuberculosis he is lost, and if possible we should remove this impression. 
I think if a case has gone on favorably for two years and there have 
been no bacilli we should call it cured. 



266 NATIONAL ASSOCIATION FOR THE STUDY 

Dr. Charles L. Greene, St. Paul : If the word " cured " is to be 
retained, my objection would lie to the interval in which to determine 
that a case had been cured. In the case of " arrest " it is put at two 
months ; " apparently cured " three months, while in the case of 
" cured " the period is two years. I do not know of anything that has 
been more damaging to the profession than statistics based upon this 
subject. Whether or not the report be accepted as it stands, the time 
limit should be extended in the two latter groups. A year is necessary 
for " apparently cured " and five years for " cured." 

Dr. C. L. Minor, Asheville : The difficulty is in the different ideas 
of the two kinds of cure, the clinical and the pathological. The clini- 
cal cure is what we are working for. To those who work in resorts 
a patient who has been practically well for two years is considered as 
justified in the use of the word " cure." The retention of the term 
would have a bad effect upon the encouragement of the idea that the 
disease is distinctly curable. We do not expect to totally eradicate it 
but if a patient can return to normal and keep it for two years the 
term should be accepted. 

Dr. L. F. Flick, Philadelphia : I believe that perhaps the best thing 
we can do is to adopt the results as presented simply because we can- 
not agree upon anything better. I think perhaps two years as a test of 
cuie is unfortunate, although I believe tuberculosis is curable in the 
fullest sense of the word. The danger in putting it down as having 
established a cure is that it is exceedingly difficult to keep people under 
proper discipline after recovery. As soon as a man thinks he is well 
he disregards the method of living which made him so. There is some 
danger in conveying the idea that a man is well in the sense that he 
will not have a recurrence of the disease no matter how he lives. " Res- 
toration to physical health " is better than " cured." This is the most 
difficult part of the treatment of tuberculous subjects, i. e., to get 
them to continue to live the proper kind of life to keep them cured. 
We should not discourage people nor should we let them commit sui- 
cide by misleading them. A man must live a certain kind of life all 
his life even after he has been apparently cured. 

Dr. F. I Knight, Boston: I think that the efforts of this Com- 
mittee should be sustained and adopted without any efforts just now 
to change them. They have done as well or better than any other 
Committee could and their report will give us a working basis. All 
of us see points which we might improve upon but I think that not- 



AND PREVENTION OF TUBERCULOSIS 267 

withstanding all the little objections which occur to every one of us, 
we should adopt the report and try it and then we can discuss it more 
intelligently afterward. 

Dr. Jay Perkins, Providence, moved that the report of the Q)m- 
mittee be adopted as read. Carried. 



REPORT OF THE COMMITTEE ON EARLY DIAG- 
NOSIS OF TUBERCULOSIS 

Dr. a. C. Klebs, Chicago, Chairman 
Dr. J. H. MussER, Philadelphia 
Dr. F. Billings, Chicago 
Dr. J. C. Wilson, Philadelphia 
Dr. H. R. M. Landis, Philadelphia 



The diagnosis of phthisis, of that well-developed stage of pul- 
monary tuberculosis, offers no difficulty whatever; the symptoms are 
well marked and typical, the pulmonary signs easily discoverable, the 
expectoration contains bacilli; the clinical picture is so typical that 
mistakes in diagnosis cannot well be made, even by the superficially 
trained observer. But this stage of pathological development in the 
great majority of cases is reached only after very long periods, during 
which all signs and symptoms are less typical, less marked from that 
time on when infection took place. During this time, which marks 
the true incipiency of the malady and which anatomically is character- 
ized by the formation of a few isolated tubercles in lymph glands or 
lung tissue, no or only vague general symptoms exist, none on which 
to base a positive diagnosis of the disease. Investigation has shown 
that such infections are of very frequent occurrence, and that only in 
a comparatively small percentage of these cases does the disease de- 
velop further. However, this percentage is sufficiently large to make 
tuberculosis the most destructive of all diseases, and the demonstra- 
tion of its frequent and spontaneous arrest and of its curability by 
certain therapeutic measures at an early period of its development, 
must induce efforts of recognition long before the stage of phthisis 
is reached. 

The discovery of the tubercle bacillus in the sputum of patients 
suffering from the disease constitutes a diagnostic means of indis- 
putable accuracy. However, the consideration alone of the fact that 
tubercle bacilli can appear in the sputum only after the caseification 
and breaking down of a tubercle situated near a bronchus or bron- 

268 



NAT. ASS'n for study AND PREV. OF TUBERCULOSIS 269 

chiolus makes it certain that tuberculous changes occur previous to 
the appearance of the bacillus in the sputum. This is borne out also 
by the clinical observation of a recognizable stage of tuberculous lung 
involvement, before bacilli are found in the sputum and the adoption 
of the term " closed," designating this stage, in opposition to " open," 
i. e., with bacilli found in the sputum, can be recommended for a more 
general introduction. 

From the therapeutic standpoint the diagnosis of pulmonary tuber- 
culosis in its closed stage is of the utmost importance, the chances of 
permanent recovery diminishing proportionally with the postpone- 
ment of rational therapeutic measures. These measures, being on the 
whole nothing but a radical change in the patient's mode of life, will 
also interfere less with the patient's usual occupations, the earlier the 
diagnosis is made. Hence, also, for this reason, the paramount im- 
portance of an early diagnosis. The physician who declines to make 
a positive diagnosis of tuberculosis on account of the absence of the 
bacillus in the sputum only, assumes a very grave responsibility, and 
great caution in this respect cannot be urged sufficiently. Whenever 
certain signs and symptoms justify a suspicion of the disease, without 
there being positive evidence, it is wise to instruct the patient care- 
fully as to his mode of life, to watch him closely and to repeat the 
examination at stated intervals. 

As regards the examination, it may be said in general that a close 
and careful investigation of constitutional as well as local manifesta- 
tions by the simplest methods will often reveal sufficient evidence for 
a positive diagnosis. The search for bacilli in the sputum has un- 
fortunately brought about a neglect of these methods. 

The history of the patient may or may not contain useful infor- 
mation; it ought to be carefully investigated in every case. Predis- 
posing moments, such as cases of tuberculosis in the family and among 
intimates or unhygienic mode of life, dusty and confining occupations, 
must all be taken into consideration; their absence in one case, on the 
other hand, must not discourage further examination. 

The symptoms of incipient tuberculosis will rarely offer anything 
typical. We may have a very early hoarseness or a condition re- 
sembling that of chlorosis or neurasthenia, of bronchitis or dyspepsia. 
Cough may, or may not, be present. Haemoptysis in the absence of 
other causes, among all the symptoms, which may be found in the 
history, is one of the greatest significance. Physical signs are some- 



270 NATIONAL ASSOCIATION FOR THE STUDY 

times absent for weeks after the haemoptysis. Vague as all these symp- 
toms may be and characteristic for various morbid conditions, they 
assume diagnostic value only when considered together with the re- 
sults of a careful physical examination. 

Here inspection first of all will have to reveal conditions of 
stature and physical development, which in their deficiencies we know 
to be indicative, if not of the disease itself, at least of a predisposition 
to it. Length and weight of body, circumference and degree of ex- 
pansion of chest, are data of importance, and in their correlation give 
indication of the bodily condition and state of nutrition. Still we must 
not depend on finding often the classical habitus phthisicus, the para- 
lytic thorax, if we are to make an early diagnosis of tuberculosis. How- 
ever, these data as well as the determination of symptoms are of 
greatest value, if for nothing else but a guidance in subsequent ex- 
aminations, and for that reason should not be neglected in any case. 

Of great importance is the temperature. Even a slight rise of 
temperature in the afternoon, if other causes can be excluded, ought 
to arouse invariably our suspicions. Very often this is overlooked, 
and to shield against such oversight great care in the measuring of 
the temperature is to be recommended. Whenever possible, a two- 
hourly record for a period of several days ought to be taken, a good 
thermometer to be placed in the mouth with tightly closed lips and 
held there for at least five minutes, the patient in a room of even 
temperature. It will also have to be remembered that in some tuber- 
culous patients the rise of temperature appears only after some ex- 
ercise, in women before and at the time of menstruation. 

The physical examination of the chest by inspection, palpation, 
percussion and auscultation, if carefully and properly performed, will 
give more direct evidence than other methods. It may be said here 
that the newer methods of examination, notably that with the Roentgen 
rays, cannot, at least, in their present state of development, claim 
superiority over the results obtained by the above-mentioned methods. 

Attention shall be called here only to a few signs indicating limited 
lung involvement. On inspection very often a retardation in the res- 
piratory movements over the affected lung portion can be observed, 
especially over one apex. This retardation is more pronounced in a 
more recent involvement of the corresponding area of the lung. (Tur- 
ban.) Foci of greater extent diminish the excursions of the diaphragm* 
of the affected side. This can be demonstrated on the fluorescent 



AND PREVENTION OF TUBERCULOSIS 27 1 

screen, but equally well and without apparatus by the observation of 
the diaphragmatic excursions by means of Litten's shadow. 

The vocal fremitus in early pulmonary tuberculosis gives little 
information. It may be increased or decreased over areas of pleural 
thickening; over pleuritic exudations it is always diminished. 

Painstaking percussion and auscultation of the chest, over all 
parts and always comparing the two sides, is of the greatest value. 
The use of the blue pencil for marking the border lines and deter- 
mining the excursions of the lungs, cannot too strongly be urged. 
Strong percussion, on the whole, should be avoided. Marked dullness 
is but rarely found over portions of the lungs in incipient tuberculosis ; 
however, the percussion will elicit sometimes a significant retraction 
of one apex as compared with the other. 

In judging the results of the examination by auscultation, it 
should always be remembered that many of the signs are subject to 
considerable variation, depending on the time at which the examina- 
tion is made. Rales which we can easily discover in the morning will 
regularly be absent during the afternoon. Also on damp and rainy 
days we will find them when they are absent in dryer weather. Also 
do we find in women pulmonary signs accentuated at the time of 
menstruation. 

All these circumstances must be considered before a final judg- 
ment of the case is given. 

Although every portion of the lung (including the lingula over 
the heart dullness) should be examined with the stethoscope, particular 
attention will have to be paid to the upper portions of the lungs and 
also to the lower borders and the axillary regions. 

As the earliest auscultatory sign in early pulmonary tuberculosis 
we can regard the rough and the sUghtly diminished respiratory mur- 
mur. The former must not be confounded with the sharp (puerile) 
respiratory murmur, which is more a sign of increased function than 
of swelling of the mucosa. Both are vesiculary sounds; the rough 
character is produced by a succession of murmurs, following each 
other too rapidly for aural differentiation. Is the succession less rapid, 
then we speak of an interrupted respiratory murmur, which suggests 
much coarser changes. Thus the rough murmur changes the char- 
acter of the respiratory sound, it loses its " smooth " quality and be- 
comes " impure and roughened." (Sahli.) When these adventitious 
sounds become audible beside the vesicular murmur, then we can 



2^2 NATIONAL ASSOCIATION FOR THE STUDY 

speak of rales. The rough murmur is produced by slight inflam- 
matory changes in the bronchioli, the air passing over an uneven sur- 
face and through a slightly narrowed lumen. It is principally audible 
during inspiration over the apices and below the clavicles. This 
murmur precedes the appearance of rales (not the case, as a rule, with 
the puerile murmur), and thus is the earliest auscultatory manifesta- 
tion of tubercular involvement of the air passages. Distinct attention 
should be paid to it therefore. The appearance of rales over the apices 
(also in the axillary region) is next to it in importance. Rales indi- 
cate catarrhal conditions; with them the intensity of the vesiculary 
murmur is usually diminished, which is also produced by the more 
pronounced swelling of the bronchial mucosa. In the earliest stages 
we hear usually fine crackling rales; they can often only be heard 
directly after the patient has coughed. 

Bronchial respiration we hear but rarely in early tuberculosis; 
when it appears, we have to deal with a more extensive process. By 
its localization in the apices and together with other signs it is, of 
course, pathognomic of consolidation; the same may also be said as 
regards the other deviation from the normal respiratory murmurs, 
which are indicative of profound tissue changes, to discuss which does 
not come within the scope of this report. On the other hand, pleuritic 
friction is often heard at an early period, most frequently in or near 
the axillary line between the sixth and eighth ribs. 

Only passing mention can be made of other diagnostic methods, 
of which tuberculin is the most important. Although it is well under- 
stood that by injection of small doses of tuberculin and by the febrile 
reaction thus produced in tuberculous individuals, we can diagnose early 
tuberculosis, the method necessitates great care in its application and 
an apparatus too complicated for general use, so that it does not lend 
itself to a more general introduction. The dangers of the preparation 
in the hands of one well acquainted with the method are very slight, 
but by applying carefully the other means of observation and examina- 
tion, a case will rarely be found in which it would add considerably to 
the information gained. 

The fact that certain salts, especially iodine salts, increase catarrhal 
symptoms and thus make them more perceptible to auscultation, has 
led to their administration for diagnostic purposes. For similar reasons 
as the above stated, a general introduction of this method cannot be 
recommended. 



AND PREVENTION OF TUBERCULOSIS 273 

The examination with X-rays has the drawback of a complicated 
apparatus. Besides, its value over the other methods has not yet been 
satisfactorily demonstrated. 

Various other methods have been advocated for the early detection 
of tuberculosis, — inoscopy, sphygmography, sphygmomanometry, se- 
rum test, etc., all apt to increase our knowledge of the disease, but of 
no practical advantage in the every-day diagnosis of so frequent a dis- 
ease. The careful and painstaking application of the methods well 
taught and well understood, with the simplest apparatus, but applied 
with a broad conception of the pathogenesis of the disease, will bring 
about much earlier diagnoses than are usually made. 

DISCUSSION ON THE REPORT OF THE COMMITTEE ON 
EARLY DIAGNOSIS 

Dr. Edward G. Janeway, New York: The report is an admirable 
representation of methods of early diagnosis of tuberculosis. The 
failure to recognize the disease in its early stages is partly due to lack 
of care and partly to lack of reexamination. If a physician finds no 
signs he says you have no tuberculosis and this is one of the first 
dangers, as he should remember that there may be an absence of 
physical signs and yet the presence of the disease. There should be 
perhaps four or five examinations before pronouncing that a person 
has no tubercular trouble. More frequent examinations should be 
made of suspected cases. 

I well remember a case of a man who had died of yellow fever on 
whom I made an autopsy. He was an engineer on one of the Ward 
Line steamers. He had in his lung two foci, one in the middle por- 
tion of each upper lobe, but nothing else in the lungs or elsewhere of 
a tubercular nature. His family physician said he had never had any 
symptoms of tuberculosis, but his wife said he had had haemoptysis 
three years before. This man had practically been cured, although he 
had a nodule in each lung. Too little is often made of haemoptysis. 
Phthisis should always be suspected in these cases, but we must except 
certain conditions, (i) Malingering. I remember the case of a new 
student who pricked his gum and as a result of the bleeding he secured 
a trip to Europe. (2) Mitral stenosis is one of the frequent causes of 
haemoptysis. These people are sometimes considered tuberculous. 
(3) Spitting of blood is sometimes called tuberculosis in a healthy 
person. These cases show the limitations in diagnosis. 



274 NATIONAL ASSOCIATION FOR THE STUDY 

There is such a thing as auditory hallucination. We may hear 
very fine crepitation which does not mean anything much. In some 
cases haemoptysis is a life preserver and if a patient has had this he 
will do anything you want. Sometimes patients are told that the blood 
comes from their nose or throat; this is carelessness. Nothing has 
struck me more than the late stage at which patients are supposed to 
have incipient tuberculosis. I never tell a person he is not a fit sub- 
ject for a sanatorium or that it would do him no good. These con- 
siderations make one feel that very careful attention to physical signs, 
temperature, repeated examinations and frequent weighing are of the 
utmost importance. Simply find the first signs and watch them after- 
wards. This report is judicious and well placed and I have only made 
these remarks to express my thanks to the committee. 

Dr. Frederick I. Knight, Boston: That the earliest possible rec- 
ognition of any pathological condition is of supreme importance to a 
good physician needs no argument. Why in pulmonary tuberculosis 
has the diagnosis until recently been made, as a rule, so late? This 
has happened especially in two classes of cases; in one of these the 
disease begins in an insidious, chronic way, with slight cough, usually 
in the morning, and little or no disturbance of the general health. In 
these cases the delay has been due largely to the fact that both phy- 
sician and patient have avoided the recognition, until it was forced 
upon them, of a condition which was considered almost surely fatal. 
In the other class, commencing in an acute way, the fever has been 
such a marked symptom and the cough so slight that the patients have 
been treated for malaria or typhoid fever for weeks, and in the case 
of the former disease sometimes for months, before the true nature of 
the affection was recognized. The true nature of still another class 
of cases, beginning with anaemia, or nervous dyspepsia as noted espe- 
cially by Carnot, has been too often overlooked. 

Since the possible curability of the disease has been proven, a 
curability more likely in proportion to its incipiency, diagnosis has been 
attempted much earlier, especially by the younger men of the pro- 
fession, usually with beneficent results to the patient, but occasionally 
otherwise, for, as in modern surgery brilliant results of operative work 
have led to many operations without the most exact diagnosis pos- 
sible, so sometimes cases have been diagnosticated pulmonary tuber- 
culosis on insufficient grounds, and patients subjected to an unneces- 
sary breaking up of home and business. Therefore, while I urge the 



AND PREVENTION OF TUBERCULOSIS 2/5 

earliest possible diagnosis, it should be a diagnosis carefully reasoned 
out. We should not, however, wait in all cases for a positive diagnosis 
before putting our patients with suspicious symptoms under the best 
possible conditions for recovery. 

The difficulties of the situation are complicated by the fact that 
it is not wholly pathological tuberculosis but also clinical tuberculosis 
that we must seek, not the presence of tubercle merely, but whether, 
if found, it is in a situation and present condition to cause the symp- 
toms which have excited our apprehension. We must start with the 
knowledge in mind that a large proportion, perhaps a majority of those 
we are called upon to examine, have foci of tubercle somewhere in 
their bodies, and for this reason especially tuberculin injection is not 
of great clinical value, as it gives no indication of the location or con- 
dition of the deposit. 

The presence of tubercle bacilli in the sputum in an incipient case 
would, of course, usually be evidence enough to warrant us in radical 
treatment; but this may not occur, and to make an early diagnosis of 
active tuberculosis in an incipient case without it requires a very 
careful examination and weighing of evidence to enable us to give 
an opinion which is likely to affect the whole subsequent course of 
a patient's life. The more symptoms and signs we have in combina- 
tion, the more probable the diagnosis, but we must in the absence of 
any sign which may be considered pathognomonic, investigate them 
very carefully to be sure that no other cause is likely. 

Haemoptysis, for instance, though due in a majority of cases to 
pulmonary tuberculosis, may be due to other causes, and I have known 
a patient who had this symptom to be treated in a special sanatorium 
and afterwards sent to Colorado, in whom it was probably due to valvu- 
lar disease of the heart. Cases of haemoptysis, riot followed by cough or 
fever and without physical signs in the lungs or heart, must be kept 
in the doubtful category. The same may be said of other symptoms. 

The failure to show the strength of a combination of symptoms 
as compared with the weakness of single symptoms contributed largely 
in my opinion to the loss of a recent case in court by one of our large 
life insurance companies. The company was sued for insurance which 
it declined to pay on the ground that the insured had consumption, and 
knew it, at the time he was insured. The counsel for the beneficiaries 
interrogated one of the principal medical witnesses, who had examined 
the insured years before he took out the policy as follows: 



276 NATIONAL ASSOCIATION FOR THE STUDY 

" Now, doctor, answer me ' yes ' or ' no,' does dullness at the apex 
of the lung always denote consumption ? " 

" No." 

" Do moist rales at the apex always denote consumption? " 

" No." 

"Does spitting of blood always denote consumption?" 

" No." 

" Do tubercle bacilli in the sputum always denote consumption ? " 

" No." 

And all the evidence of this witness was lost because the attorney 
for the company in his cross-examination did not ask : " Does a com- 
bination of these signs not almost invariably denote consumption ? " 

Perhaps I would not be wrong in saying that since laboratory and 
other exact methods of physical examination have been perfected, too 
little attention is sometimes paid to the general condition of the patient. 

I wish, however, at this time to call attention especially to errors 
in physical diagnosis. It is altogether too common nowadays to make 
a positive diagnosis on slight physical signs. A patient should not be 
condemned to radical treatment on slight changes in the percussion 
note and respiratory murmur, or a shadow or deficient expansion as 
seen by the X-rays, unless these have arisen under our observation, 
for they may be due to an old lesion long quiescent. Here the same 
difficulty confronts us, as when examining a cardiac case for the first 
time, to know whether a murmur is an old one, or due to an acute 
endocarditis. 

When a patient presents himself we should first get as accurate 
a history as possible of previous sickness or ailments, especial attention 
being paid to such symptoms as might have been due to lung affec- 
tion. If there have never been such symptoms, and the patient was 
presumably healthy up to the present illness, so much the more weight 
can be attached to what we find on physical examination. If there 
have been suspicious symptoms in the previous history, physical signs, 
especially slight ones, if unaccompanied by constitutional disturbance, 
must be weighed with great care. 

Dr. DeLancey Rochester, Buffalo: As to the general condition 
of the patient and especially the time and character of the pulse, I 
think in the present day we neglect the latter entirely too much. If 
we have a perceptibly increased pulse of low tension it is important. 
If we have an anaemia with leucopsenia in association, these are very 



AND PREVENTION OF TUBERCULOSIS 2^^ 

pronounced constitutional symptoms that should make us suspicious, 
and a careful physical examination should be made more than once. 
In fact all possible examinations should always be made and I will 
relate one case to illustrate this. The patient, a man, had a cough for 
three months ; previous history negative ; chest examination showed 
no evidence of tuberculosis; temperature 99°, pulse 84, small and low 
m tension; some expectoration; blood examination not made. An 
examination of the nose and throat should always be made and in this 
case this examination showed the nose to be deformed. I told him to 
send me a specimen of sputum and call again. He expectorated 
three c.c. in twenty-four hours and some tubercle bacilli were found to 
be present, although the condition of the nose and pharynx would 
easily have accounted for the sputum he was raising. When I again ex- 
amined him there were a few crackling rales at the apex of the right 
lung. Cases with a rising temperature should be examined several 
times, as in tuberculosis this is a most valuable aid to early diagnosis. 
Dr. Theodore Potter, Indianapolis: I have been interested in ex- 
perimenting in order to find out the deficiency of medical students in 
this matter of early diagnosis and I endeavor to find out the con- 
dition of the students at the end of the junior year. This year I 
asked the junior class to state the symptoms and physical signs of 
early diagnosis and I received a very fair answer to the first part of 
the question, but when it came to the matter of the early physical 
signs it would be appalling to see the lack of knowledge. In only 
three instances out of eighty did I get a fairly good answer and I 
shall now endeavor, during next year, to correct some of their de- 
ficiencies. One reason for this deficiency is that we select typical cases 
illustrating typical signs, such as bronchial breathing and prolonged 
expiration, and the students fail to get proper instruction in the early 
physical signs. There is where our chief defect in this matter is. We 
select the typically pronounced cases and fail to teach the physical 
diagnosis in the early cases. I confess that I have been led more and 
more to use tuberculin as a diagnostic agent. Sometimes people come 
to see us and request a positive and definite diagnosis at once if pos- 
sible, and I have felt compelled to reach such a positive diagnosis as 
quickly as possible in some cases. There are two groups of cases 
who force you to do this: (i) There is the ignorant class who want 
to know everything at once and they expect you to reach positive re- 
sults quickly. In those cases I have felt compelled to use tuberculin. 



278 NATIONAL ASSOCIATION FOR THE STUDY 

(2) There is also the very intelHgent class of people who want to do 
everything they can for themselves and do not want to wait. In such 
cases I have been led to use the tuberculin diagnosis and I confess with 
considerable satisfaction. 

Dr. Howard S. Anders, Philadelphia: I was particularly inter- 
ested in the reference which Dr. Janeway made to the association of 
mitral stenosis in the question of diagnosis. I think also that mitral 
stenosis may enter into the hsemoptitic aspect of early diagnosis. I 
remember two patients, both semi-emaciated, anaemic women, without 
evidence of tuberculosis but with streaks of blood in the sputum, where 
mitral stenosis was proven to be present. Mitral stenosis has been 
followed by apiceal tuberculosis six months later. Many cases of 
mitral stenosis have occurred in my experience in a class of cases 
that seem to be suffering from incipient tuberculosis. Whether or not 
people suffering with this condition are more or less susceptible to 
tuberculosis I do not know, but the type of physique may indicate 
this. As to the question of procedure, it is not always well to pay 
too much attention to expansion. Some of the very earliest signs 
may sometimes be missed by asking the patients to take a deep breath. 
As to auscultation you may miss what was there before the patient 
took two or three deep breaths. The discovery of a small area of dull- 
ness does not always indicate this. Tuberculous people are habitually 
poor breathers, and if we do not ask them to take a deep breath we 
may sometimes be deceived as to the true nature of their trouble, 
while on the other hand asking people to take deep breaths may also 
mislead us. 

Dr. Alfred Meyer, New York: As to mistaking auscultatory 
signs, I get around this difficulty by making a second examination 
of suspected points after I have made a cardiac examination, I have 
my patients hold their breath and quickly listen to the points under 
suspicion. As to the haemoptysis in mitral stenosis I believe most men 
will agree that the literature rather indicates the association of pul- 
monary tuberculosis with mitral stenosis, but I believe the opposite is 
more likely to be the case. As to the coincident existence of the mitral 
stenosis and areas of dullness, these cases have often had haemoptysis. 
Years afterwards you may find some variation in the auscultatory 
murmur and I do not see why this should not be the case. The ques- 
tion arises as to whether the case is not one of mitral stenosis with 
an old infarct. 



AND PREVENTION OF TUBERCULOSIS 279 

Dr. S. E. Solly, Colorado Springs : I regret very much the slight- 
ing way in which the X-ray was treated in the report, as I regard it 
as extremely valuable and often of great service. 

Dr. C. L. Minor, Asheville: I think it is worth while to call the 
attention of the gentlemen present to the use of the thermometer, as 
I find it a very variable instrument. They are all claimed to be per- 
fect, but I am very suspicious of them. Of late I have been using 
an English make. I secured no less than six dozen, some of which I 
sent to the government to be tested. It is worth while to be sure that 
every one is all right on the authority of some good man and not 
simply on that of the maker. We make a mistake in not keeping a 
careful chart of every step in the treatment. If we would always, and 
without exception, keep a chart showing step by step we would not 
be so liable to make omissions. I thank Dr. Klebs for dwelling upon 
the importance of the blue pencil. It is a very important matter and 
only by its aid can you satisfactorily determine these cases. 

Dr. F. M. Pottenger, Los Angeles : We are so apt to look for too 
much and we are at times inclined to blame the general practitioner 
for not finding some things that are present. I believe, however, that 
while the diagnosis is one of the most difficult to be made, yet with 
the physical examination, personal history and tuberculin test we can 
diagnose tuberculosis with a practical certainty even though it requires 
considerable time. The diagnosis should never be made on one ex- 
amination. This matter should never be done in a hurry, but should 
be given all the time that is necessary. 

Dr. John H. Pryor, Ray Brook : I regard this article as one of the 
safest and most judicious that I have ever heard. It will undoubtedly 
be published and for this reason I would like to make a suggestion. 
Could it not possibly be made to include a reference to the change in 
the pitch of the voice or whisper? If you have a sufficient consolida- 
tion so that you get a decided change in breath sounds I have found 
that you will not notice a difference in the pitch of the inspiratory 
sound, but you are very apt to detect a higher pitch to the whispered 
sound. 

Dr. G. Mannheimer, New York : Turban considers rough breathing 
the very earliest sign and I wish to emphasize this point. The Ger- 
man and French literature refers to it, but it must not be confounded 
with increased vesicular breathing or with interrupted breathing or 
with adventitious sounds. Thr explanation is that it is due to the 



28o NAT. ASS'n for STUDY AND PREV. OF TUBERCULOSIS 

swelling of the mucosa of the bronchioles. Turban thinks it is due to 
minute scattered areas of tuberculosis, the air entering these parts of 
the lungs in jerks. It is not absolutely characteristic of tuberculosis, 
but it is so often found after repeated examinations. I believe that 
we not only need an understanding of the stages of the disease, but 
also as to the meaning of our physical signs, as no ten of us would 
agree as to what certain physical signs mean. 

Dr. W. L. Dunn, Asheville : We are apt to go a little too far into 
the " refinement of interpretation." We misinterpret the slight signs 
and call them tuberculosis. I do not mean to decry the most careful 
work in this line. I would like to speak a word in behalf of tuber- 
culin. We should make a positive diagnosis if possible. Our patients' 
interests frequently demand the use of the tuberculin test and in these 
cases it should be done. If we can arrive at a diagnosis by other 
means it should not be used, but otherwise it should be. 

Dr. Arnold C. Klebs, Chicago : I wish to thank the gentlemen on 
behalf of the Committee, I feel, like the chairman of the Nomen- 
clature Committee, that we cannot expect to agree on every point. We 
simply wanted to bring out the most important points. This report 
will be read by the practitioners throughout the country and we there- 
fore kept it within these limits. 

Dr. V. C. Vaughan, Ann Arbor, moved the adoption of the 
report as read and the motion was carried. 



RESULTS OF THE OPEN AIR TREATMENT OF 
SURGICAL TUBERCULOSIS 

By W. S. Halsted, M. D. 
Baltimore 



Planned and partly written more than ten years ago, this paper 
was not completed until last Autumn (1904) when the private clin- 
ical material seemed large enough and to have been observed long 
enough to make the report convincing. Even now my list of private 
cases of surgical tuberculosis is not a long one. It is not to be ex- 
pected that people accustomed to luxury, and, particularly, when in 
poor health, should relish the prospect of a winter in a boarding house 
at Saranac. I am, therefore, under great obligations to the patients 
who have so courageously and with such implicit trust yielded to my 
very earnest solicitations to exile themselves for a winter at least. To- 
day we cannot well realize the amount of faith which this required fif- 
teen years ago when not a single precedent could be cited, when one 
could indicate no case of surgical tuberculosis which had been treated 
in even a most desultory out-of-door fashion, and when patients, en- 
couraged to believe that they would get well if they remained at home 
and in doors, asked me to explain how mountain air, inhaled ever so 
deeply, could reach the bone. 

The Sanatorium of Dr. Trudeau at Saranac Lake had been in 
existence only about four years when, in 1889, soon after my call to 
the Johns Hopkins University, I first met him and one afternoon 
listened for hours, charmed by the story of his life, his work, and 
his dreams for the future. He eagerly welcomed the suggestion that 
possibly all cases of tuberculosis, irrespective of the situation of the 
lesion, might be benefited by the treatment which he believed was 
proving to be of great value for pulmonary tuberculosis. The milder 
the case, or in other words, the more nearly perfect the patient's im- 
munity, the greater, presumably, was the prospect of cure. Hence, 

281 



282 NATIONAL ASSOCIATION FOR THE STUDY 

cases of bone and lymph-gland tuberculosis which, under various 
names, had for tens of centuries been regarded as more or less curable 
and certainly as infinitely less to be dreaded than " consumption," 
seemed eminently proper ones for the open air treatment. 

There is abundant evidence from France, and especially from 
England, as to the genuineness of the cures of struma and of rickets 
by the laying on of the King's hand. The practice can be traced in 
England to Edward the Confessor (tio66) and in France to Philip 
the First (fiioS) " Le Roi te touche, Dieu te guerit." From the of- 
ficial register it appears, for example, that 90,798 persons suffering 
from the "King's Evil" were touched by Charles II (1660-1664 and 
1669-1682).^ John Browne, Chirurgeon in Ordinary to His Majesty, 
the author of four treatises (1684) on the subject gives a figure even 
larger in his Charisma Basilicon, or the Royal Gift of Healing Stru- 
maes, or King's-Evil, Swellings by Contact, or Imposition of the 
Sacred Hands of our Kings of England and France, given them at 
their Inaugurations. 

Shakespeare refers to the custom (Macbeth, Act. IV, Scene III) : 

Doctor. Ay, Sir: there are a crew of wretched souls 
That stay his cure : their malady convinces 
The great assay of art; but, at his touch, 
Such sanctity hath heaven given his hand, 
They presently amend. 



Macduff. What's the disease he means? 

Malcolm. Tis called the evil; 

A most miraculous work in this good King; 
Which often, since my here-remain in England. 
I have seen him do. How he solicits heaven, 
Himself best knows; but strangely-visited people, 
All swoln and ulcerous pitiful to the eye, 
The mere despair of surgery, he cures, 
Hanging a golden stamp about their necks, 
Put on with holy prayers : and 'tis spoken. 
To the succeeding royalty he leaves 
The healing benediction. 

The cost of these golden stamps in certain years was more than 
3,000 pounds, sterling; so great that in Elizabeth's reign silver coins 
were substituted for the gold. Many of the best known English sur- 
geons, Goddesden, Gale, Clowes, Bannister, from the 13th to the 17th 

^Gurlt, Geschichte der Chirurgie. 



AND PREVENTION OF TUBERCULOSIS 283 

century, testify to the marvellous results of this practice.^ Is it not very 
likely that the exposure to all weathers day and night, the life in the 
open, led by the afflicted on their long pilgrimages to Norway, France, 
England, effected the cures of the King's evil and deserved all the 
glory enjoyed by the monarchs endowed with the miraculous touch? 

Though the knowledge of opsonins was a little indefinite in the 
early Adirondack days, it was evident that, in a general way, improve- 
ment in nutrition, whatever that signifies, is responsible for the subsi- 
dence of the disease. After my talk with Dr. Trudeau a year passed 
before the patient destined to be the first to make the true experi- 
ment in the treatment of surgical tuberculosis presented himself. But 
in the meantime we were accumulating evidence of a less conclusive 
kind on the " bridge " of the Johns Hopkins Hospital. The open air 
treatment of surgical tuberculosis possibly began with the admission 
of the first tuberculous patient to the surgical wards of this Hospital. 
He was wheeled in his bed to a spot on the roof of the long corridor. 
A rough trundle-bed had been constructed for the purpose of trans- 
porting beds easily from the wards to the bridge and to the clinics.^ 
Although at first the surgical beds on the bridge afforded amusement 
for most except those whose duty it was to trundle them, very soon 
the benefit to the patients was so definite and evident that even cer- 
tain non-tuberculous patients, particularly those convalescing from 
other infections, were also treated to fresh air. Just the other day, 
for example, a child about eleven years old, operated upon for ap- 
pendicitis, had a septic post-operative temperature, ranging from 
loi* to 106" F. for nearly three months. Whether general infection 
or an undiscoverable local focus of infection was responsible for the 
temperature has never been determined. Her haemoglobin sank to 
25%. Finally, when her life was almost despaired of, she was trans- 
ported to the bridge and, seemingly from that moment, her convales- 
cence and prompt recovery began. 

It is a real joy to patients, this life in bed on the bridge. It 
relieves the monotony of the confinement and they discover that it 
gives appetite and sleep and vigor. After a severe surgical operation, 
patients, if restless and sleepless, often find that the day out of doors 
in bed refreshes and soothes them and insures a peaceful night and 

'Gurit, 1. c. 

* The idea and the design for this trundle we brought from the great clinic 
of Volkmann in Halle where it was used to transport beds from the wards 
to the amphitheatre, and from ward to ward. 



284 NATIONAL ASSOCIATION FOR THE STUDY 

a morning minus the headache incident to an anodyne. And what 
a boon it must be to the typhoid convalescents, to those suffering 
from the so-called post-typhoid septicaemia. The main rectangular 
corridor is twelve feet wide and more than 1,300 feet long: hence, 
the length of the veranda or " bridge," its roof, is about one quarter 
of a mile. I have intended for years to ask the distinguished designer 
of the Hospital, Dr. J. S. Billings, if he had in mind any such possible 
use for the bridge when he planned it. This treatment of patients 
with surgical tuberculosis has been carried on uninterruptedly for the 
past sixteen years; and now, every day, with few exceptions, winter 
and summer, the bridge is strewed with the sick. 

But it is from my private parties that I have learned the almost 
incredible value of the true out-of-door living in the treatment of 
surgical tuberculosis. 

I have treated no patient, the Hospital cases excepted, who would 
not or could not live out of doors in the manner prescribed. 

There follows a brief abstract of all the private cases, and, here- 
upon, the fuller histories of the first four of these which latter were 
the pioneer patients, the experimental cases, and have been under 
observation for many years. They were, also, serious cases, whose 
progress has been watched with unusual concern and satisfaction. 

Case I. — Pott's disease with sinuses. Enormous waxy liver. In bed, 
very ill, and supposed to be dying when he consulted me in 1890. Transported 
in private car to Saranac Lake. Restored to fair health, married, father of 
three children, lived twelve years, died of nephritis. (Fuller history follows.)^ 

Case II. — Child, set. 15. Family history of tuberculosis. Hip disease 
one and a half years. Large abscess in or about joint (Feb., 1893). Iodoform 
injections; rigorous out-of door treatment at home in Maryland and moun- 
tains of Pennsylvania for seven years; then (Jan., 1900) to Adirondacks, where, 
in five weeks, she gained nine pounds. On her return she looked really well, 
for the first time since my first examination. Brace and crutches were dis- 
carded, and riding, driving, walking, dancing and social pleasures were freely 
indulged in with true relish after the long weary years of life in a chair on 
the piazza. But day after day and night after night our patient's strength was 
taxed (1900 and 1901) and the hours on the piazza became fewer and fewer and 
finally none. Then, in less than two years (from the time "cured": Dec, 
1901) she noticed a little swelling and stiffness above the right wrist for which 
she soon consulted me. Her general condition was poor, almost bad. Diagno- 
sis : Tuberculosis of tendon sheaths. At operation a very active and extensive 
process from palm to upper third of forearm was revealed ; thousands of fresh 
tubercles in sheaths and muscles were carefully removed. Patient went eagerly 

^ All of the cases are given in detail at the end of this paper. 



AND PREVENTION OF TUBERCULOSIS 285 

and promptly after the operation to Saranac, where in the first month she 
gained 16 pounds. The winter was spent in the Adirondacks and the summer 
in the Austrian Tyrol. May, 1903. Patient enjoys perfect health. She walks 
with a hardly noticeable limp. Flexion permitted to a right angle at affected 
hip, although the head of the femur has disappeared. The slightly expanded 
end of neck occupies the acetabulum. The function of hand and wrist is per- 
fectly restored. Results like this, very rare in the past, will be common in the 
future. (Fuller history follows.) 

Case III. — Mrs. d, set. 28. March 1894. Sister died of pulmonary 

tuberculosis, aged 36 years. Is very delicate and neurotic. Fluid in right knee 
joint. Typical tender points. Iodoform injections, at my suggestion, by the 
late Professor Dabney of Charlottesville, Va. Life out-of-doors in Virginia 
conscientiously carried out. June, 1894, no improvement. Adirondacks urged, 
but not feasible. Injections continued by Dr. Dabney. October, 1895, disease 
progressing rapidly. Resection considered. November 5, 1895, patient pre- 
sented herself in Baltimore for operation. She coughed and had fever. Exam- 
ination of lungs revealed apical involvement. Consented to go to the Adiron- 
dacks. Pulmonary hemorrhage en route. Weight, 86 pounds. Normal weight, 
104, greatest weight, 112 pounds. Arrived at Saranac, examined promptly by 
Dr. Trudeau. His prognosis guarded but rather unfavorable. On subsequent 
examinations it proved that the disease, though incipient, was still advancing; 
prognosis more decidedly unfavorable. For several months no improvement, 
then a slight gain, and in August, 1896, she weighed 95 pounds, a gain of 9 
pounds in about 9 months. Circumstances made Adirondacks too difficult. 
The mountains of Western North Carolina were suggested, but patient was so 
much encouraged that she returned to Virginia. There she slowly but surely 
lost ground. Eventually, October, 1897, she made her home in the North Caro- 
lina mountains. The lesson learned at Saranac was of great value here. She 
lived the true, open-air life faithfully. 

In September, 1898, I found astonishingly great improvement in the condi- 
tion of lungs and knee, and in a few months discontinued the plaster cast. In 
May, 1899, weight 97 pounds. In January and February, 1900, she visited in 
Virginia and lost much ground. Possibly developed a slight pleurisy. Re- 
turned to North Carolina and gradually regained what was so rapidly lost. 
November, 1900, knee still better. January, 1901, motion in knee returning. 
Then a second visit to her home in Virginia; again, and promptly, a pleurisy; 
she became so ill that it was difficult to return to North Carolina. January, 
1903, examination. I could hardly believe what I saw. The right knee joint 
looked perfectly normal, except for a very slight fulness on either side of liga- 
mentum patellae. (Fuller history follows.) 

Under Dr. Thayer's care this patient has gained more than twenty pounds 
within a few months; he is unable to find a trace of the pulmonary disease 
which at one time was so active as to seriously menace her life. 

Case IV. — Miss 1, aet. 38 years. Tuberculous family (sister, uncle 

and aunt). Hip joint disease, initial stage. Tuberculin reaction. Modified 
open-air treatment in Pennsylvania for eight months. Through misunderstand- 
ing, considerable exercise was taken. Disease made such definite progress 
that I became alarmed and urgently advised Adirondacks. Immediate and 
great improvement in general and local condition at Saranac Lake. Brace and 
crutches discarded three years after first examination. Motion at hip joint 



286 NATIONAL ASSOCIATION FOR THE STUDY 

almost perfect. Unless very careful comparisons with the other hip are made 
there is no indication of impairment of function. Even the apparent shorten- 
ing (adduction) which the brace could not overcome and which persisted for 
nearly three years has vanished. Only the reaction to tuberculin remains. (Ful- 
ler history follows.) 

Case V. — Miss m, aet. 14. In September, 1900, fell, striking right 

hip. Bruise over right trochanter. Attended school regularly. Consulted me 
about four months later for limp and occasional pain in right knee. Patient 
seemed in good health but had lost a little in weight and perspired easily. 
There was about 1.5 cm. apparent lengthening of the right leg, but no differ- 
ence in circumference of thighs and legs on the two sides. Hardly demon- 
strable limitation of motion in any direction; little if any rigidity of the ad- 
ductors of the thigh. Extreme hip movements caused pain in the knee of the 
affected side. Tuberculin was administered three times at her home. The 
reaction was very slight but definite, becoming more pronounced as the dose 
was increased. Definite pain in the hip itself was experienced for the first 
time a day or two after the exhibition of the third dose of tuberculin. 

February 13, 1901, admitted to the John Hopkins Hospital. Supplied with 
brace and treated on the " bridge " until May 13, 1901. While in the hospital 
she was entirely free from pain except for occasional brief twinges in hip and 
knee. 

From the Hospital patient went to Atlantic City for a few weeks and thence 
to the Adirondacks for the remainder of the summer. During the following 
winter it seemed so difficult to arrange for the patient's departure to the 
Adirondacks that she was permitted to live in town, spending her days, how- 
ever, out-of-doors on a balcony. In the spring she had lost so much in weight 
and her general condition was so unsatisfactory that I almost insisted upon a 
change. Tuberculin again administered, was followed by a prompt reaction, 
the temperature reaching 103° F. A winter in the Adirondacks completely 
restored our patient to health. 

May, 1905, two years after the institution of treatment, a cane was sub- 
stituted for the brace. In a few months the cane was discarded and patient 
has led the active life of a young society girl ever since. She has no pain nor 
limp and seems perfectly well. 

Case VI. — Mrs. J n, set. 34. Admitted October, 4, 1902. Diagnosis, 

sacro-iliac tuberculosis. Two years ago pleurisy in left side. No night sweats 
and no shortness of breath. 

Present illness began in April, 1902. Patient felt slight twinge in back 
on getting into carriage. Next day had severe pain in region of sacro-iliac 
synchondrosis. Since then patient has suffered constantly. 

Exam.: Considerably emaciated. Gums pale. No tenderness on pressure 
over spines of vertebrae. Over right half of sacrum is a slight fulness and over 
this some tenderness. Tenderness also in sciatic notch and along sciatic nerve. 
Little if any tenderness over Poupart's ligament on right side, except on very 
deep pressure. In August, 1902, in Virginia, patient's ovaries and appendix 
were removed. 

Oct. i6th, operation, cocaine. Dr. Halsted. Aspiration of tuberculous 
abscess over sacro-iliac articulation. Iodoform emulsion injected. 

Nov. I, operation, ether, Dr. Halsted. Exploration of right sacro-iliac 
joint. Excision of the walls of a tuberculous abscess and of a portion of the 



AND PREVENTION OF TUBERCULOSIS 287 

sacrum. A large abscess was discovered in the pelvis communicating with the 
one above. The walls of the pelvic abscess were cleaned as well as possible, 
but some portions were inaccessible from this opening. 

Feb. 3. Since operation patient has been kept out of doors, in bed, but 
her weight, which is normally 135 pounds, is now only 98. She has been most 
carefully instructed as to the life out-of-doors, and has promised to follow di- 
rections implicitly. Discharged. 

April 8, 1904. Patient returns for examination. She is in perfect health 
and weighs 150 lbs. Since leaving the hospital, two years ago, she has lived 
out-of-doors faithfully in all weathers; has slept in doors but with windows 
wide open. The sinus leading to the pelvis is closed. There is no sign of 
disease in the pelvis or at the site of the incision in the back. She complains 
of nothing except that on standing she has slight pains along the course of 
the sciatic and external popliteal nerves. Extreme flexion of thigh sometimes 
produces this pain. Patient is not annoyed by it. 

Case VII. — Miss B e, aet. 16. Admitted to the John Hopkins Hospital 

March 25, 1904. About three months ago patient noticed that her neck on 
both sides was swollen and believed the swelling to be due to " cold." The 
" puffiness " soon subsided, leaving " knots " in its place. These have grown 
rapidly ever since. There has been no pain nor tenderness and, patient believes, 
no loss in weight; she confesses to some loss of strength. The voice has be- 
come husky. Patient is becoming drowsy and has tendency to sleep continually. 
No cough. 

Exam.: On both sides of the neck are large masses of discreet glands 
varying in size from a pea to a madeira nut. Together they would probably 
equal a cocoanut in volume. Left axilla contains six or seven glands; the 
right seems free. The left epitrochlear is palpable. No enlargement of glands 
of groin or popliteal space. No masses to be felt in abdomen. Spleen not 
palpable. Tonsils markedly enlarged. Circumference of neck at level of 
hyoid bone 34 cm. On the back of the right hand is a scar from incision for 
the removal of a small growth, believed at the time to be a ganglion, but 
which proved to be a solid mass. There is now an elongated, semi-fluctuant 
swelling apparently connected with the tendon sheaths. A small gland re- 
moved for diagnosis proved to be tuberculous. It was proposed to patient 
and her friends that the out-of-door treatment be tried and, in case it failed, 
operation be undertaken. The patient being indisposed to undergo the rigorous 
out-of-door life, Dr. Follis, the house surgeon, excised, with cocaine, the tu- 
berculous glands of the left neck and left axilla. ' 

April loth, patient discharged, having promised to live systematically out- 
of-doors. Wound healed per primam. 

Readmitted May 12, 1904. Since discharge patient has lived out of doors, 
day and night, without interruption. Though she has had only one month of 
this treatment, the glands on the right side of the neck have almost entirely 
disappeared. Only one can be felt and that exceedingly small. On the back 
of the left hand, however, at the site of the old scar and running along the 
tendon sheaths there is evidence of a tuberculous process. 

May 13th. Excision of tuberculous tissue about the extensor tendons over 
the left wrist and dorsum of hand by Dr. Follis. The disease was found to be 
quite extensive. 

June 6th. Patient discharged. Condition excellent. No enlargement of 
glands of neck. On the operated side, however, is a keloidal, disfiguring scar. 



288 NATIONAL ASSOCIATION FOR THE STUDY 

Case VIII. — M s, set. 25. Admitted April 11, 1904. Tuberculosis of 

right knee. About three years ago, after prolonged standing, experienced first 
pain in the right knee. He was treated for acute rheumatism for six months, 
the knee joint being aspirated 25 times. The fluid withdrawn was dark and 
turbid but never bloody. On one occasion an injection of carbolic acid solution 
(1-16) was used. Patient's knee gave him "little trouble apparently until Sept., 
1903. 

Exam.: Joint much enlarged. Patella floating. No redness, heat nor 
especial tenderness. Leg can be flexed to about a right angle. April 13, 
tuberculin administered. Marked local and general reaction. April 25, ar- 
throtomy, under ether, by Dr. Follis. A considerable amount of purulent look- 
ing tuberculous fluid was evacuated and the joint thoroughly irrigated with a 
solution of bichloride of mercury (i-ioooo). The capsule was found thickened 
and oedematous, but there was no evidence of bone foci nor destruction of 
cartilage, nor caseous tissue. On June 4th Dr. Follis persuaded patient to go 
to Saranac Lake in the Adirondacks, and arranged for his admission to Dr. 
Trudeau's Sanatorium. Discharged to-day. 

April II, 1904, patient readmitted to hospital. Since his discharge he has 
been continuously at Saranac Lake. The knee has been fixed in a leather splint. 
Patient has gained ten pounds since leaving hospital. He has no cough nor 
night sweats and appetite is good. 

April 14, two milligrams of tuberculin administered, followed by severe re- 
action. 

Examination of Knee: The joint is spindle-shaped, there being con- 
siderable atrophy of the thigh muscles. The patella is movable and there is 
little or no fluid in the knee joint. There are no points of especial tenderness 
on pressure but attempts to flex the joint beyond perhaps 15 degrees cause 
great pain. The findings are somewhat disappointing but patient is not dis- 
couraged and agrees henceforth to live out-of-doors at night, as well as in the 
day time, at his home in Montgomery, Ala. Discharged March i8th. 

Oct. 16, 1905, patient readmitted to the hospital. Since March he has lived 
out-of-doors night and day in Montgomery, Ala. and has noticed from the be- 
ginning gradual improvement in the condition of the knee joint. He looks in 
robust health, has had no pain in knee or elsewhere. Has used crutches and 
a leather splint. Exam. — The knee seems perfectly cured. Flexion is permitted 
without any pain to an extent almost normal. Except for the scar and the barely 
perceptible fulness in its neighborhood, for which the scar is probably respon- 
sible, the joint in appearance is perfectly normal. 

Oct. 13, two milligrams of tuberculin are followed by sharp reaction, the 
temperature arising abruptly to 102. 

Case IX. — Miss n, set. 17. Consulted me last March. Below the 

parotid in the common situation on the jugular vein was a mass of matted 
glands, larger than a big lemon. They had increased in size rapidly during 
the few weeks prior to this consultation. Not wishing to alarm the young lady 
unnecessarily, I did not give tuberculin at once but sent her to the seashore with 
a skilled attendant for out-of-door treatment. In about a month she returned 
for inspection. The mass had increased in size and become fluctuant in the 
most prominent part, and the skin over it was inflamed and at one spot slightly 
thinned. Tuberculin administered was followed by a sharp reaction. About to 
sail for Europe, I doubted very much the wisdom of postponing operation, and 
debated the matter in my mind for several days. Argument. If an operation 



AND PREVENTION OF TUBERCULOSIS 289 

were performed, it would not make the out-of-door treatment unnecessary or 
even shorten it. If the skin should break, the resulting scar would be much less 
than the operative one. The rupture of the abscess would not be attended with 
any bad results, nor would it, that we know, prolong the open air treatment or 
create local conditions less likely to respond to this treatment than if the skin 
were unruptured. If ultimately an operation should be required, it would al- 
most surely be of less magnitude and at a time when the patient was more robust. 
Moreover, it transpired that our patient had, at the seashore from which she 
had just returned unimproved, lived only five or six hours daily in the open 
air. So we decided to give the open air a fairer trial. She went to the coast 
of Maine and lived out-of-doors day and night for about four months. A few 
days ago, on her return to town, I examined her and to my joy found that only 
one of the enlarged and inflamed glands was palpable and this no larger than 
a French bean. The redness of the skin had entirely disappeared and I do not 
believe that any one, from the appearances, could have designated the side which 
had been affected. To surgeons whose daily bread not long ago was tuberculous 
glands of the neck (Cohnheim), such a resolution foretells a revolution in treat- 
ment. 

Cases X and XL — Two cases of tuberculosis of the urinary bladder, 
adult males. Operated upon by the author at the Johns Hopkins Hospital in 
1892 and 1893. In one the entire mucous membrane of the bladder was thickly 
studded with tubercles ; in the other the involved area was small and the disease 
incipient. Both cases have been kept constantly under observation since their 
discharge and both are in good health. The one with the severe and extensive 
lesions was able to lead the out-of-door life quite constantly. He is well. The 
other, with the comparatively trivial lesions, has trifled with the treatment and 
is not perfectly well, although very much better than when he was operated upon 
about IS years ago. The histories of these cases are not at hand, so I am un- 
able to report them in full and to give exact dates. 

I 



The More Complete Histories of the First Four Cases 

Case I. — In February, 1890, the writer was summoned to see Mr. n, 

who at the time was so ill that his life was despaired of by his relatives. The 
patient, aged 28, received a severe fall when 3 years old, to which was attributed 
the illness and spinal curvature which thereafter speedily developed. At the 
age of 14, incident to a second fall on his back, an abscess developed rapidly and 
discharged, in the right groin. It soon closed, but only to reopen and close again 
at intervals ever since. In the winter of 1888 and 1889 abscesses appeared and 
opened spontaneously in the left groin and above the crest of the left ilium. 
Thereupon the patient's health declined rapidly until March, 1890, when my first 
visit was paid him. 

At this time he had sharp lower-dorsal kyphosis, an enormous liver and 
three sinuses, one on each side below Poupart's ligament, and one above the 
crest of the left ilium. For several weeks the patient, considerably emaciated, 
had experienced chilly sensations, and occasionally a real chill, with high fever. 
He was evidently suffering from retention under tension of the products of 
inflammation, which, I believed, from rather indefinite symptoms, would point 
over the right ilium. As he was very feeble and exceedingly nervous, as the 



290 NATIONAL ASSOCIATION FOR THE STUDY 

indications for immediate operation were not perfectly clear, and as his life at 
home involved considerable excitement, I urged him to go at once to Saranac 
Lake in the Adirondacks, intending to visit him later and to liberate the pus if 
the symptoms should persist. It required very little argument to convince this 
highly intellectual and accomplished man that it was well worth while to make 
the experiment. He was transported on a bed in a private car from Baltimore 
to Saranac Lake; this patient was a pioneer, and possibly the very first case of 
bone tuberculosis deliberately treated by the open-air method. In the Adiron- 
dacks, attended by an excellent masseur, he lived in a tent, and almost imme- 
diately after arrival an improvement in his general condition began, although 
there were periods when the daily fever would be considerable. 

In October, 1890, I visited him at Paul Smith's, where he had located his 
tent, and performed a slight operation to liberate the pus on the right side above 
the crest of the ilium. Two years, with occasional visits to his home in Balti- 
more, were spent in the Adirondacks. In this time the patient was Hterally 
transformed in appearance. Weighing less than 100 pounds on arrival, he gained 
nearly 40 pounds from April, 1890, to November, 1891, and on his return to 
Baltimore he affirmed that he had never felt better in his life. His good health 
continuing, he became engaged, and in about two years he married. After his 
marriage he spent a part of two or three winters in the Adirondacks, with great 
benefit to his health. Occasionally I found it necessary to dilate one or more 
of his sinuses in order to liberate their pent-up discharges. On the 29th of July, 
1902, the patient died, the immediate cause of death being an exacerbation of 
the nephritis, which had existed for 12 years at least. The liver, which was very 
large and extended below the umbilicus at my first examination, steadily in- 
creased in size during the subsequent twelve or thirteen years. In the last four 
or five years of his life he suffered on two or three occasions from attacks of 
acute nephritis, precipitated apparently by the toxaemia resulting from obstruc- 
tion in one or other of the sinuses. 

This was a life clearly rescued and prolonged by the Adirondacks and Dr. 
Trudeau. This patient had such confidence in the ability of these mountains to 
restore him at any time that he lived not only a most unhygienic but actually 
reckless life at home, repairing to Saranac Lake only when his condition suffi- 
ciently alarmed him. Three superb children survive him to bless the Adiron- 
dacks and the physician there who made their introduction to this world possible. 
Consideration for his wife and children, he often told me, would not permit him 
to make his home in the Adirondacks. A few days after his death his sister 
wrote me that " of the large circle of acquaintances made in the Adirondacks, only 
one of those who were suffering with tuberculosis is alive to-day. My brother, 
although apparently the illest of all, survived them. In other words, I believe the 
treatment promises more for bone trouble than for pulmonary tuberculosis." I 
quote this, of course, merely to give the impression of an intelligent lay-observer. 
That this patient could have been rescued elsewhere than in the Adirondacks 
is quite likely, but having tested the mountains of Virginia, the sea coast of 
New Jersey and Maryland, he had faith only in the Adirondacks. One Christ- 
mas about two years after his introduction to the Adirondacks he returned to 
Baltimore and, though wearing a heavy overcoat on a mild winter day, com- 
plained bitterly of the cold. " I am wearing today an overcoat for the first time 
this winter," said he, " although the thermometer has been as low as 20 degrees 
below zero in the Adirondacks. Up there one is insensitive to the severest cold, 
but here one shivers on a mild day." His masseur walking with him had already 
made the same remark to me. 



AND PREVENTION OF TUBERCULOSIS 29I 

Case II. — Miss n, jet. 15, consulted me for the first time in February, 

1893. For about 18 months she had suffered with pains in her right hip and knee. 

Tuberculosis on both maternal and paternal sides was conspicuous in the 
family history, but the patient had been perfectly healthy until the onset of the 
present trouble. Examination : Right thigh much flexed and slightly adducted. 
All motions of hip joint greatly restricted. There was so much fulness about 
the right hip that an abscess was suspected, and a needle aimed at the joint was 
readily introduced into a space believed to be or to communicate with the joint 
cavity. The point of the needle could be removed freely as if in an abscess, 
and from one and a half to two ounces of a glycerine emulsion of iodoform was 
at the next consultation injected without meeting resistance. Patient was kept 
in bed in a large, freely ventilated room, with extension, from February until 
June, 1893. During these four months, five or six iodoform injections were 
made. After the first two or three injections it was difficult to find the abscess 
cavity. A light Bruns' splint was applied and, faithfully following my urgent 
advice, the patient lived out of doors thenceforth; extension was kept up at 
night. For the ensuing five years she spent from six to eight hours daily in 
the open air. The summers of these years were lived in the low mountains near 
Wilkesbarre, Pa. Patient's general health was fairly good most of the time, 
but she was far from robust, and her appetite was unsatisfactory. The eight 
or ten pounds which were gained each summer in the mountains of Pennsylvania 
were lost in the winter. 

In June, 1898, patient was admitted for a few days to my service in the 
Johns Hopkins Hospital, for measurements and a skiagraph. The summer of 
1899 was spent at Jamestown, Rhode Island. No gain in weight was made at 
the seashore and patient returned to her home near Baltimore unimproved, and 
out of conceit of the seaside. In January, 1900, patient was again admitted to 
the Johns Hopkins Hospital for careful examination subsequent to a period in 
which greater liberties in walking had been permitted. It was deemed wise to 
make an exploratory incision before permitting patient to dispense entirely with 
her crutches. The result of this operative examination was most satisfactory. 
The head of the femur had been entirely absorbed but the neck was intact and 
perfectly normal, its free end occupying the remains of the acetabulum. A 
narrow, deep groove was cut anteriorly into the neck for its entire length but 
not the slightest evidence of disease was discovered. The slight shortening 
which had been observed on Bryant's line was evidently due solely to the loss 
of the head of the femur. The capsule of the hip joint was intact and motion 
between the articulating inner end of the neck and tjie acetabulum was remark- 
able in its freedom. Nature had accomplished what a surgeon by operation could 
not possibly have done. The surgical operation, even the most conservative, is 
necessarily destructive, unless nothing more is attempted than the removal of 
inflammatory products or of tissues already destroyed. Patient was discharged 
February 7th, having been detained in the Hospital, after the operation, only 
2H weeks. 

January 8, 1900, the day before the exploration of the hip, the red blood 
corpuscles were 3,250,000 ; the white 6,000, the haemoglobin 52%. 

January 28, ten days later, and nine days post-operation, the haemoglobin 
was 65%. February 3, haemoglobin, 65%. 

Comparing the measurements made by me in June, 1898, with those made 
independently by my house surgeon, Dr. Cushing, 18 months later, it is interest- 
ing to note that the relative differences are precisely the same. This would in- 



292 NATIONAL ASSOCIATION FOR THE STUDY 

dicate that the disease had made no progress whatever and that the measure- 
ments were exceedingly accurate. 

June 7, 1898. Measurements by W. S. Halsted. 

Apparent difference in length of the legs, none. 

From anterior superior spine to trochanter, on projected vertical line, 

Left. Right. 

(a) Vertical line (Bryant's) 2.2 cm. 1.9 cm. 

(b) Ant. sup. spine to int. malleolus 83.9 cm. 80.9 cm. 

(c) Top of trochanter to ext. malleolus 84.1 cm. 81.0 cm. 

(d) Length of femur 44.6 cm. 44.1 cm. 
January 17, 1900, two days before the exploration of the hip. 
Notes by H. W. Gushing. 

Apparent difference in length, none. 

Left. Right. 

Ant. sup. spine to int. malleolus 83.0 cm. 80.0 cm. 

Trochanter to ant. sup. spine (Bryant's line) 4.5 cm. 4.0 cm. 

No muscle spasm. Internal and external rotation only slightly limited if 
at all. Extension to straight line and flexion permitted to 45 degrees or more, 
notwithstanding the prolonged fixation of the joint. 

The measurements, all of them (a, b, c, d), indicate abduction, particu- 
larly (b) the measured difference from ant. sup. spine to internal malleolus 
and (c) the difference in the actual length of the entire extremity. The apparent 
upriding of the right trochanter is in part due to the abduction. That there is 
so little measured difference (0.5 cm.) in the length of the femur, notwith- 
standing the growth of the patient, might suggest a thickened right trochanter. 
But the loss of the head of the femur, together with the abduction, should 
sufficiently account for the 1.9 cm. shortening in Bryant's line. How shall we 
interpret the fact that the difference (3 cm.) in the length of the lower extremi- 
ties is almost entirely in the leg unless we assume that the disease stimulated, 
as it sometimes does, the growth of the bone on its confines? The circum- 
ference of the calf was the same on the two sides, whereas there was a dif- 
ference of 4 cm. in the circumference of the thighs, fifteen centimetres above 
the patella. The shortened leg was larger and the atrophied thigh was longer 
than expected. 

From the Hospital the patient went to the Adirondacks for five weeks 
and while there gained eleven pounds. She learned for the first time the true 
meaning of living out-of-doors and was so conscious of the great and prompt 
benefit received that she regretted the long doubtful years lived on the piazza, 
at home. It is but just to myself to state that at the first consultation and 
often subsequently I had suggested and even urged the Adirondacks, but was 
unable when questioned as to the relative merit of localities to affirm that the 
Adirondacks alone promised relief, or more certainly promised it than the moun- 
tains elsewhere. I could only answer that the Adirondacks had been tested 
more thoroughly and more scientifically than any other region in this country 
and, what was most important, the patient residing there would be under Dr. 
Trudeau's supervision and would learn to lead the proper life. 

On her return from the Adirondacks the crutches were abandoned and our 
patient promptly found great enjoyment in life, riding, driving, walking, dancing 
and indulging freely in the pleasures of society. Finding the out-of-door life 
irksome and incompatible with the new life, into which, after the long confine- 
ment, she was entering so naturally and with so much relish, the hours on the 



AND PREVENTION OF TUBERCULOSIS 293 

piazza became fewer and fewer until finally in the winter (1900-01) there was 
none. Day after day and night after night during this winter our patient's 
strength would be tested to the extreme limit of endurance. The summer of 
1901 was, in greater part, passed in Maryland. About the first of December 
(1901) I was consulted concerning a little swelling and a little stiffness about 
the right wrist joint, which had been observed for about two months. Tuber- 
culosis of the tendon sheaths being diagnosticated, our patient, who had lost in 
weight and strength, was at once admitted to the Johns Hopkins Hospital and 
promptly operated upon. 

There was much oedema of the tendon sheaths. Fresh, translucent tu- 
bercles thickly studded the connective tissues and muscles of the forearm, par- 
ticularly the tendon sheaths, from the palm of the hand to the upper third of 
the forearm. A very careful dissection of the tissues involved and excision of 
the disease was made. December 18, about two weeks after operation, the 
patient was discharged, and about January i, 1902, eagerly started for the 
Adirondacks. Arrived at Saranac, she began to improve in health immediately, 
gaining 16 lbs. in the first month. The remainder of this winter and the fol- 
lowing spring were passed at Saranac, the best of health being enjoyed. The 
summer was spent in the Austrian Tyrol. 

April 8, 1905. Patient has enjoyed perfect health, almost without inter- 
ruption, since her return to the Adirondacks in January, 1902. For the past 
2H years she has lived at her country home, near Baltimore. To-day she is 
the picture of health. The affected forearm, wrist and hand present a normal 
appearance, except for the scar, and perform their functions quite normally. 
Patient would be rarely reminded of the fact that her right hip joint was once 
the site of serious tuberculous disease were it not for a very slight limp suggest- 
ing the use of a cane when she is tired. 

This case teaches us that time is of great importance in the treatment of 
tuberculous joints in fast-growing children, because of the shortening which 
results, particularly from disuse. In this case the shortening from disease re- 
presented by the difference in the height of the trochanter, is only 0.5 cm. 
whereas the difference in length of limb from trochanter to malleolus is 1.25 cm. 

Case IH. — Mrs. d. First consultation March 16, 1894. Married two 

years before at the age of 26. 

In November, 1894, lost a sister, set. 36, of pulmonary tuberculosis. 

About the first of March, 1894, patient " felt a slipping sensation " in the 
right knee. History of traumatism could not be elicited. She at once consulted 
the late Dr. Dabney, Prof, of Medicine in the University of Virginia, and by 
Dr. Dabney was referred to me. 

Exam. March 16, 1894. A delicate looking, very slender, nervous and 
emotional young woman; and always enjoyed good health until about two weeks 
ago when she began to worry about her right knee. There is slight limitation 
of motion; a little disability; some fluid in the joint; and apparent thickening 
of the capsule; two or three typical tender points. The lungs and other organs 
are reported normal. 

Diagnosis, tuberculosis of the right knee. 

I advised Dr. Dabney to fix the knee in plaster and to make iodoform 
injections into the joint, and urged the patient to lead at her home in the south, 
the Adirondack life which I described to her. Four injections were made by 
Dr. Dabney from April 7th to May i8th. 

June isth. Second consultation. Finding the knee unimproved, I advised 



294 NATIONAL ASSOCIATION FOR THE STUDY 

change of residence to the mountains, preferably the Adirondacks. Mountains 
nearer home, altitude 1900 ft, were visited because residence in the Adirondacks 
was not feasible at this time. Dr. Dabney made a fifth iodoform injection, 
June 20th, and a sixth July 12th. In August he died. The 7th, 8th, 9th and loth 
injections were made by me in Baltimore in Oct. and Nov., 1894, and Jan. and 
March, 1895. About Oct., 1895, I advised resection of the knee, as the disease 
was advancing, as the patient's health was becoming decidedly impaired, and as 
a winter in the Adirondacks was deemed impossible by the patient and her 
husband. Patient returned to Baltimore Nov. 4, 1895 for operation. For two 
or three weeks patient had coughed occasionally. Nov. 5th I carefully examined 
the lungs and feared that both apices were becoming involved. Nov. 6th a 
second examination confirmed my fears. The operation was consequently post- 
poned and the patient urged to go at once to the Adirondacks. Nov. 8th she 
expectorated a little blood just before starting for the Adirondacks. At this 
time her weight was 86 pounds. Her normal weight was about 104, and her 
greatest weight 112 lbs. 

Soon after her arrival at Saranac Lake, Dr. Trudeau made several careful 
examinations and feared that the disease, although incipient, was rapidly ad- 
vancing and gave an unfavorable prognosis. For several months there was no 
improvement but the patient held her own and finally began to gain in weight and 
in August, 1896, weighed 95 pounds. She then felt compelled to leave the Adiron- 
dacks, contrary to Dr. Trudeau's advice and my earnest solicitations. I suggested 
the higher mountains of Western North Carolina as an alternative, but patient was 
so much encouraged that she decided to go again to the mountains nearer her 
home in Virgina. Slowly but certainly losing ground, she eventually, in October, 
1897, went to the Western North Carolina mountains. Having learned in the 
Adirondacks how she should live and what the out-of-door life meant, she 
lived out of doors in all weathers faithfully, and became very fond of the life. 

In September, 1898, I found great improvement both in her general health 
and in the condition of the knee. Early in 1899 the patient's casts were discon- 
tinued. In May, 1899, patient located permanently in Hendersonville, N. C. 
The altitude of her private residence there is about 2250 ft. Her weight at this 
time was 97 lbs. Full of hope of ultimate recovery she visited, without my 
consent, her relatives in Virginia in January and February, 1900, and as she 
wrote me, " lost considerable ground." On returning to Hendersonville, it was 
two or three months before she regained what she had lost. 

In November, 1900, I had the pleasure of seeing my patient and finding her 
general condition somewhat improved and her knee disproportionately so. 
January, 1901, patient writes that the knee is surely becoming less stiff. 

A little later patient ventured, against my most urgent warning, another 
visit to her home in Virginia, to see her aged mother whose health was not 
good. She had an attack of "pleurisy" while at home and only with difficulty 
could return to Hendersonville. 

Some months later (January, 1903), she writes from Hendersonville that she 
weighs only 85 lbs., that her "health is extremely frail," but that the knee is 
" vastly improved." She " can bear some weight on it " and goes " about the 
house with only one crutch." " Creaking and grating in the joint if exercised 
still noticeable to sense of hearing and touch. Motion very nearly normal." 

September 28, 1903. Met my patient, by appointment, on a railway train and 
examined the knee joint. In appearance the joint, except for a very slight ful- 
ness on either side of the ligamentum patellae, showed nothing abnormal; the 
patient flexed and extended her knee rapidly and without the least apprehen- 



AND PREVENTION OF TUBERCULOSIS 295 

sion. Flexion of the left or sound knee could be carried only 5 or 6 degrees 
further than that of the right. There were no tender points. That such a res- 
toration of function could take place in this knee, at one time so seriously in- 
volved, I would have believed hardly possible. It was the more remarkable be- 
cause the patient's general health was very poor indeed. She was highly neurotic, 
suffering from tongue and stomach neurosis, and weighed only 76 lbs. I had no 
opportunity to examine the lungs, but was assured that she had neither cough 
nor expectoration, and rarely if ever had a night sweat. Her respiration was not 
rapid as she sat quietly in the car, nor was there anything in the voice or facies 
to indicate implication of the lungs. 

There can be little doubt that this patient's life was saved by the Adiron- 
dacks and the North Carolina mountains. She believes that she gained more 
rapidly in the former than in the latter region. The almost disastrous results 
of the two trips to her home in Virginia were probably not due so much to the 
journey, which was not a long one, as to the change of residence, for she had 
repeatedly taken hard, all-day drives in the mountains without demonstrable 
evil effects. 

How remarkable, too, and significant, is the observation that notwithstanding 
the gradual and great loss of strength and weight, the tuberculosis process in 
both the knee and the lungs was not only arrested but has left no sign. 

Under Dr. Thayer's care this patient has gained more than 20 pounds within 
a few months ; he is unable to find a trace of the pulmonary disease which at 
one time was so active as to seriously menace her life. 

Case IV. — Surg. No. 13010. Miss 1. ^t. 38. First examination 

Feb. 7, 1902. 

Family history: Father and mother living. One uncle and one aunt on 
mother's side died of pulmonary tuberculosis. A sister had a discharging sinus 
from one hip, but was cured while still a child. Digestion has never been very 
strong, and, until eight years of age, patient could not eat breakfast without 
vomiting immediately. At 12 years her stomach performed its functions fairly 
well, but patient has always found it advisable to be abstemious. Has never had 
a chronic cough nor haemoptysis, nor observed any unusual shortness of breath. 
A year ago could mount ordinary hills on a bicycle without fatigue. Menses 
have always been regular. Has had bay fever for eighteen successive summers. 
Several of the finger joints and one ankle are enlarged from " chronic rheu- 
matism." 

Present illness: Five months ago, in September, 1901, making a false step, 
patient fell backwards, down three steps, striking 'the left hip. A slight sub- 
cutaneous extravasation of blood appeared over the left trochanter, and for 
about a week this bruised spot was tender. There was no limp nor pain on walk- 
ing and the incident was for the time forgotten. But about January, 1902, 
the left hip seemed a little stiff and occasionally felt slightly sore. These symp- 
toms the patient tried to dissipate by walking. After about a week's exercise 
of this kind a tenderness over the trochanter manifested itself. Improvement 
followed two days' rest in bed, but when walking was resumed the discomfort 
returned. The pain, described as being dull, to use the patient's words, would 
"run from hip to knee," and was usually worse at night; "it felt as though 
a cord were stretched too tightly from the hip over the knee." A few weeks 
before admission a decided limp manifested itself. Patient has never been 
awakened by sharp pains at night, has never had night sweats, but for the past 



296 NATIONAL ASSOCIATION FOR THE STUDY 

month has been conscious repeatedly of chilly and feverish sensations. For a 
year past her health has been a little below what she considered normal, her 
appetite has been impaired, she becomes readily fatigued, and has lost a few 
pounds in weight, 

Feb. 12, 1902. Physical examination: Patient is a slender, delicate looking 
woman, but is tall, erect and well formed. Thorax and abdomen negative. The 
inguinal glands are very slightly enlarged on both sides. The Hips: Inspection 
reveals a very slight apparent shortening of the left leg, possibly 0.5 cm., and 
little else. The back is flat and there seems to be no abnormal flexion of 
either hip. 

Measurements of the House Surgeon: 

Ant. Sup. Spine to Ext. Mall. Trochanter to Mall. Ant. Sup. Spine to 

Trochanter 
Left side, 85 cm. 81.5 cm. 3.7 cm. 

Right side, 85 cm. 81.5 cm. 3.2 cm. 

The 0.5 cm. difference in the length of Bryant's line, if correct, I believe 
to be due, in part at least, to the abduction of the right and adduction of the 
left leg. 

All the motions of the affected left side seem to be normal if they are 
made gently and with suitable traction. Even sudden motions are not definitely 
resisted except abduction and extreme adduction and internal rotation. Flexion 
and extension are perfect. Hyperextension seems about equal on the two sides. 

Except for the apparent shortening (adduction) the slight rigidity of the 
adductor muscles, and the tenderness over the trochanter, there are no definite 
signs of irritation in or about the left hip joint. There seems to be a little 
thickening of the left trochanter. 

Measurements made by the writer differed in no essential particular from 
those given above. To determine accurately the distance from the top of the 
great trochanter to the malleolus a tape measure seems to the writer to be un- 
reliable because one cannot make proper allowance for the distance the muscles 
permit one's finger on each side to press in over the trochanter towards the 
digital fossa. With a wooden measure, which we have constructed somewhat 
on the plan of the shoemaker's foot rule, this source of error is excluded. , 

April nth, 1902. Examination by writer, (a) Apparent shortening 1.3 
cm.; gluteal fold i cm. lower, (b) From spine to top of trochanter on projected 
vertical line (Bryant's) no shortening, (c) From anterior sup. spine to ext. 
malleolus no shortening. Measurement (c) is explained by the adduction (a). 

Rotation out 6°-7° less on left than on right side. Rotation in about 4° 
less on left than on right side. Adduction very slightly restricted, hardly demon- 
strable; rigidity of adductor muscles. Flexion and extension normal. Possibly 
slight impairment of hyperextension. Exceedingly indefinite reaction to 2 and 
4 mg. of tuberculin. After 9 milligrams of tuberculin the temperature rose to 
101° F. and patient complained slightly of headache and general malaise. The 
tuberculin at this particular period happened to be weaker than usual, and 9 mg. 
was a not uncommon dose. Patient was discharged to-day having been under 
observation for 63 days. Treatment extension by weights and pulley at night 
and brace during the day. 

The days were passed on the bridge. Patient intended to continue in all its 
details, the treatment instituted. This she did most conscientiously and intelli- 
gently under the care and heartiest co-operation of Dr. Joseph S. Miller; but 



AND PREVENTION OF TUBERCULOSIS 297 

as she has since then repeatedly assured me, she had no conception of the true 
out-of-door life as it is lived in the Adironracks under Dr. Trudeau's supervision. 

Oct. 30, igo2. Readmitted to Hospital for examination. Since first visit 
has had very little pain in hip in the day time but at night has been occasionally 
awakened by it, particularly by sudden jerkings. 

Exam.: Nov. 6, 1902. The motions at the hip joint are decidedly less 
free than at first examination, 8 months ago. Flexion, which was then about 
normal, is stopped at 85 degrees. Rotation in both flexed and extended posi- 
tions is much restricted, particularly rotation outwards. There is pronounced 
spasm of the adductors now, whereas at first rigidity was barely demonstrable. 
The trochanter is more sensitive to pressure, particularly behind just below the 
posterior superior angle and along the posterior surface. The circumference 
of both thigh and calf is 6 cm. less on left side. Four milligrams of tuberculin 
produced marked general reaction and a temperature of 102° F. The change 
for the worse in the local and also general condition is so definite that our patient 
decided, without hesitation, to go at once to the Adirondacks. 

March 20, 1903. Readmitted to the Hospital for examination after a winter 
in the Adirondacks. The change in patient's general appearance is very striking, 
although she has gained in weight only five pounds. From the appearance of her 
face and neck and body I was quite sure the gain in weight had been greater. 
Patient's voice is stronger, and her flesh much firmer. There has been of late 
no pain whatever in the hip and rarely any discomfort. 

Measurements: Apparent shortening, 0.5 cm. Flexion permitted easily to 
right angle is checked only by stiffened knee. Inward rotation about equal on 
the two sides. Outward rotation less by 3-5 degrees on affected side. Abduction 
limited about 2 degrees. Adduction same on both sides. There is no fixed 
flexion. No riding up of trochanter; indeed it is a little lower perhaps (adduc- 
tion) on the left side. Hyperextension not permitted. 

Nov. IS, 1904. The 18 months since the previous examination have in 
greater part been spent in the Adirondacks. Six of these months, lived at home, 
seemed to result in no improvement, although patient faithfully carried out the 
Saranac regime. The local improvement is so definite that I have decided to 
permit patient to discard the brace and to walk a little on the affected leg, not- 
withstanding a definite reaction both general and local to two milligrams of 
tuberculin. The rise in temperature, however, was very little, only to 100.5 
degrees and sustained for less than 2 hours. It then dropped promptly to 
normal. 

Examination: There is now for the first time no apparent shortening and 
only the slightest rigidity of the adductor muscles. The difference in the mo- 
tions of the right and left hips is too indefinite to be recorded. Patient has 
-complained a little of late of peculiar feelings in both hips, somewhat "rheu- 
matic " in character, and rather more pronounced in the right than left hip. 
During the past year she has had two or three rather severe attacks of indi- 
gestion. 

March 7, 1905. Since last examination and discard of the brace the patient 
has been getting on famously, notwithstanding a severe fall on the affected hip 
a few weeks ago. She has gained 3-4 lbs. in six months, which is a great deal 
for her. Altogether the gain in weight since patient first consulted me has been 
17 lbs. The entire three years, except the nights, have been lived out of doors. 



298 NATIONAL ASSOCIATION FOR THE STUDY 

The crutches are now discarded and the patient is permitted to walk with only 
a cane. 

The lessons taught by the forecited cases, especially the later 
ones, can hardly fail to awaken positive enthusiasm in others as it 
has in us. The recent observations tinge, however, the retrospect 
with regret that we could not have foreseen the great advantage — 
I hardly venture to say necessity — of the night out-of-doors as well 
as the day. The cases, Nos. VII, VIII and IX, which have made the 
most rapid strides, are those which have slept out-of-doors, and, cu- 
riously, happen to be those which were not treated in the Adirondacks 
or any sanatorium. These are the only patients of the series who 
have spent the entire 24 hours in the open. In one, Case VII, one 
month of this life in Virginia sufficed to completely dissipate a large 
mass of tuberculous glands in the unoperated side of the neck. Case 
VIII, one of knee-joint tuberculosis, conveys, it seems to me, a very 
significant lesson. After a winter in the Adirondacks, the entire day 
out-of-doors, and a gain in weight of 19 lbs., little, if any, local im- 
provement was demonstrable. It is quite likely, however, that we were 
unable to interpret properly or even discover the local changes. But 
after a few months, only three or four, of the night and day treatment 
in the heat of the midsummer in Montgomery, Ala., complete recovery 
and almost complete restoration of function have taken place. Now, 
it seems to be a fact that most tuberculous patients who are taking the 
out-of-door treatment under advisement progress more rapidly in 
cold weather than in hot; and our patient tells us that the weather in 
Montgomery was hot, at times very hot, while he was there in the open 
night and day. 

In Case IX, three months of the 24-hours-a-day treatment, on the 
coast of Maine, dissipated a mass of actively inflamed and softened 
glands of the neck, the skin over which had rapidly reddened and 
thinned during the 6-hours-a-day treatment at the seashore further 
South. 

I shall say nothing about climate, nor even discuss the relative 
merits of localities. I am merely emphasizing the importance for some 
patients of the 24-hours-a-day out-of-doors. When the thermometer 
registers 20 degrees below zero a night out-of-doors is not an agree- 
able prospect, and may be a difficult problem; and so there might 
arise the question, is it better to have from eight to ten hours of the 
day in the open in a cold climate or twenty-four hours in a more tern- 



AND PREVENTION OF TUBERCULOSIS 299 

perate one ?^ The advantages of a speedy recovery are so evident that 
they need not be urged. A rapidly growing boy with tuberculosis of 
the knee-joint might lose a great deal in the length of the affected limb 
unless the cure were rapidly effected. I have had such a case under 
observation. The proper treatment of this case was attended with 
such difficulties that I consented to a modified and less rigorous form 
of life out-of-doors. The disease made no progress and in less than 
four years seemed cured, but the boy had in the meantime grown per- 
haps 9 or 10 inches. The affected epiphyses had not kept pace with 
the normal ones on the opposite side and the boy has perhaps 5 inches 
shortening and incomplete mobility. If I could have foreseen such 
excessive growth or had known the merits of the twenty-four-hour 
day, I must have insisted upon the full time in the open. 

Furthermore, the prospect of years of treatment in a sanatorium, 
or away from home, or at home on a roof in the city, or simply 
camping day and night in the country, is dispiriting and not readily 
consented to by patients or friends. But a few months or a year of 
such a life, coupled with almost a guarantee of recovery might be 
anticipated with relish, and regarded as an outing combining duty and 
pleasure and immeasurable profit. 

I shall be much interested to learn the present views of Dr. 
Trudeau and others upon the relative value of localities. Several of 
my patients who had faithfully lived out-of-doors at home and abroad 
showed the first positive signs of improvement both general and local 
after a winter in the Adirondacks. Dr. Trudeau in one of his letters 
to me many years ago concerning my patients at Saranac exclaims: 
" The more I go, the more convinced I am that it is of little use to 
merely tell people to live out-of-doors. They must be provided with 
accommodations which enable them to live out-of-doors easily and 
comfortably. Special buildings must be planned and constructed for 
the purpose. Some day you will have to carry into effect your plans 
for an infirmary for cases of surgical tuberculosis. These patients 
should sleep out-of-doors all night and live out-of-doors all day, being 
provided with every comfort and convenience." And several of my 

^In the recital of Case III, describing the almost disastrous effects upon 
this patient of visits from the North Carolina mountains to her home, I may 
have conveyed the impression that a certain part of Virginia is unsuitable for 
tuberculous patients. But here the fatigue of the railroad journey, the excite- 
ment of seeing friends constantly, of living with relatives, and perhaps number- 
less little things may have been responsible for the serious interruptions of 
the convalescence. 



300 NATIONAL ASSOCIATION FOR THE STUDY 

patients, after living awhile at Saranac Lake, have written to me that, 
notwithstanding the most detailed instructions from me and from pa- 
tients who had taken the Adirondack cure, they had not until then 
learned the true meaning of the real life out-of-doors. One should, 
if possible, have the benefit of the proper influences, of place, of people, 
and most important, of the true physician, in order to acquire the stim- 
ulus necessary to the faithful carrying out of the treatment. 

I should have the greatest confidence in the efficacy of massage 
in the treatment of these cases. 

And as to the diet; is it necessary or wise to stuff our patients? 
A non-tuberculous individual is usually more vigorous if he is not 
over-fed. There is at least opportunity for the exercise of considerable 
discretion in the matter of feeding. I have particularly in mind a 
wealthy child whose days were spent out-of-doors, and who developed 
tuberculous glands notwithstanding a huge appetite and the liberal 
indulging of it; and another, reported in this series, whose seriously 
involved knee and lungs recovered completely, notwithstanding a grad- 
ual loss of weight from 104 to 76 pounds. 

Tuberculin, which for nearly 14 years has been our main reliance 
for diagnosis, has never assisted us in deciding when to discontinue 
fixation and to permit use of the affected joint. A definite reaction 
could probably be obtained to-day in all of our " cured " cases. We 
have in no instance failed to get this reaction when crutches were about 
to be discarded, and in two individuals it was prompter on release 
from the treatment than at its institution. 

That most cases of surgical tuberculosis will recover without 
operation if they are given a fair opportunity in the open-air, I am 
convinced, nor should I be surprised if it proved to be, in general, an 
easily curable disease. My hardest task in the treatment of these 
cases has been to persuade the relatives and friends and, alas, the 
physicians of the patients, of the necessity of taking so much trouble, 
of instituting a disturbance of the even tenor of the family's existence 
or of involving themselves in such unanticipated expenditure. I have 
submitted the pros and parried the cons with the parents for hours, 
and until so weary of the battle that I have vowed never again to mis- 
place so much energy. But interest in the subject, as great occasion- 
ally as in the particular patient, has usually stimulated a renewal of the 
attack. 

Unless acquainted with the lamentable results usually obtained 



AND PREVENTION OF TUBERCULOSIS 3OI 

in the treatment of cases such as those herewith presented one can 
hardly comprehend what has been accompHshed by the open-air treat- 
ment of them and realize what assurances it holds for the future. 
How eagerly we should welcome an achievement which properly cur- 
tails the indications for the practice of surgery, a therapeutic measure 
so crude and often so mutilative. In the multitude of cripples from 
the ravages of tuberculosis we find overwhelming proof of the in- 
adequacy of past and present methods of treatment. How different 
is the story just related. In not one instance did the disease make the 
slightest appreciable advance after the treatment was inaugurated. 
The restoration of function is perfect in all, save one (vid. Case II) 
and in this it is excellent. Had this patient been given the benefit of 
the night as well as the day out-of-doors, the treatment, begun in 1893, 
might have terminated in one year instead of seven. 

The greatest interest is being manifested abroad in the fresh air 
treatment of children afflicted wth surgical tuberculosis, but of its 
power for the cure of this disease there appears to be only a partial 
comprehension, the treatment consisting as a rule of a very free cir- 
culation of air through the wards in the daytime, but not at night. 
The importance of rapid cures has not been emphasized, nor has the 
possibility of such marvellously prompt results as the continuous 
out-of-door treatment furnishes been recognized. 

The work of Dr. John W. Brannan and his associates in establish- 
ing and conducting the Seaside Hospital for Children at Coney Island 
deserves the greatest praise and encouragement. 

The surgeons duty is not done when he advises his tuberculous 
patient to live out-of-doors. He must, if the patient's means permit 
and if other localities promise decidedly more than home, send him 
away and entrust him to a physician or companion who will assume 
the responsibility of insuring a continuous out-of-door life. 

Public opinion, which has compelled the skeptical physician to 
transfer his case of appendicitis to the proper surgeon, will soon hold 
the surgeon responsible for bad or even indifferent results in tuber- 
culous disease of the hip, the knee, the peritoneum. 

The literature pertaining to this subject was admirably presented 
by Dr. Herbert L. Burrell in a discourse at the annual meeting of the 
Massachusetts Medical Society, June loth, 1903. 



302 NATIONAL ASSOCIATION FOR THE STUDY 



DISCUSSION ON DR. HALSTED'S PAPER 

Dr. J. W. Brannan, New York: I feel greatly indebted to Dr. 
Halsted for this paper. Abroad this method of treatment of surgical 
cases has been followed for years, a prominent physician having 
founded a hospital in France for the open-air treatment of tubercu- 
losis in 1862. At this hospital one operation as a rule was all that was 
found necessary. As a result of this discovery a permanent structure 
was erected at Coney Island and children brought down there for treat- 
ment were kept absolutely out of doors except at night. In the autumn 
after they had been there for some months the results obtained were 
very remarkable. The French believe that it is the sea air and not 
necessarily the open air that does the work, but Dr. Halsted's cases 
did not have the benefit of this sea air. In the autumn it was decided 
to set apart one wing in the hospital for the continuance of this form 
of treatment throughout the winter and up to the present time we 
have had children there. We feared that with the onset of the cold 
weather we could not enforce this treatment, but fortunately we had a 
superintendent, a woman, who went up to Dr. Trudeau's sanatorium 
and saw the methods in vogue there of keeping the patients out of 
doors all the year around. Upon her return she was convinced that 
we could do the same thing, and as a result throughout the winter the 
windows have been down all night, the temperature at times being 
down to 28°. For half an hour morning and night, while the children 
are dressing the windows are put down and the steam is on all the 
time. I will pass around photographs of some of the children who 
came there on their backs and are now walking about. Even those 
that cannot walk are wheeled out on the porch every day and I have 
never found one who said she was too cold. Each child is completely 
clothed under the bedclothes and they also have hoods and mitts. I 
have been obliged to wear my hat in the wards, but the children would 
not be cold. I will pass around the photograph of a child with Pott's 
disease, whose expression shows that she is a happy individual, which 
is the usual result of the treatment. The children are glad to get out 
of doors and they were playing on the beach about Christmas time be- 
fore a bonfire. Eleven cases of hip disease with a total of 28 sinuses ; 
9 cases of Pott's disease, osteitis of the knee, ankle, forehead and 
fingers ; 35 joint and bone cases including (fj sinuses represent a part 



AND PREVENTION OF TUBERCULOSIS 3O3 

of the work done and some children who came down with sinuses now 
have none at all. 

Dr. Alfred Meyer, New York: I would like to know something 
about the use of tuberculin in the bone cases, as I understand it is said 
to do more good in tuberculosis of the soft tissues than in bone, and I 
would also like to know something of its method of administration. 

Dr. Wm. S. Halsted, Baltimore: We use Dr. Trudeau's prepara- 
ration and method, employing two milligrams to begin with in an 
adult and one milligram in children, increasing the second dose to four 
milligrams. A third dose is very rarely needed. 



REPORT OF THE COMMITTEE ON THE INFLU- 
ENCE OF CLIMATE IN PULMONARY TUBER- 
CULOSIS 



Dr. C. L. Minor, Asheville, Chairman 

Dr. E. R. Baldwin, Saranac Lake 

Dr. Norman Bridge, Los Angeles 

Dr. C. F. McGahan, Aiken 

Dr. Henry Sewall, Denver 

Dr. S. E. Solly, Colorado Springs 



The beneficial influence of wisely selected and properly used cli- 
matic influences in the treatment of pulmonary tuberculosis has been 
one of the accepted facts of therapeutics for centuries, attested by an 
enormous mass of satisfactory clinical evidence from the days of Hip- 
pocrates and Celsus until our own. In medicine, however, there is a 
wise and healthy tendency to take up and re-examine the foundations 
of our beliefs and it is not to be regretted therefore that in the past few 
years, since the general profession has been taking such a lively inter- 
est in tuberculosis, there has been a movement to question whether the 
accepted teaching as to the roll of climate in the disease is founded on 
proven facts and your Committee feels that an examination of the basis 
of our faith in climato-therapy in tuberculosis is therefore timely. 

To the observer in the health resort the evidences of the beneficial 
or curative effects of climate are so many and so apparently irrefutable, 
he so constantly has occasion to see them, and to be convinced of their 
reality that he has difficulty in understanding how they can be doubted. 
To the practitioner in other regions who has often hoped from climate 
for impossibly good results in hopeless cases and whose experience in 
the handling of the disease is limited, the relapse of a partly arrested 
case on its return home or the failure to improve of some case in a re- 
sort seems to him to justify such doubts. The former while having 
ample clinical opportunity is apt to be suspected of partiality and of 
being affected by his personal interests, the latter lacks the clinical 

304 



NAT. ASS N FOR STUDY AND PREV. OF TUBERCULOSIS 305 

opportunity and is thus handicapped in drawing his conclusions. Yet 
let us remember that after all it must be by honestly made and scien- 
tifically recorded and interpreted observations of the practitioner in 
the health resort combined with the detailed watching and after-study 
of the case by the home doctor that this question shall finally be settled 
and it is most desirable that these men should get together and study 
the matter impartially. If we look for the causes of the tendency to 
doubt the value of climate they are to be found, first, in the unskillful 
use in the past of climate as a therapeutic measure; secondly, in the 
formerly widely spread belief in a mysterious specific influence of cli- 
mate which led to a superstitious faith in its unaided powers and there- 
fore to a neglect of those even more important matters, hygiene, diet, 
mstruction and detailed supervision ; third, in the effect on the general 
profession of their recent and all too limited experience with outdoor 
treatment at home, which has caused them to go from the extreme of 
an undue hopelessness in the past to that of an equally unwise hope- 
fulness that any case can be cured in any atmosphere by sleeping out 
on a porch and eating freely. 

As to the first cause, cases after a diagnosis have too often been 
sent to a resort to care for themselves with no better instructions than 
to live outdoors and to take plenty of exercise and food, the doctor for- 
getting that he would censure any man who would use any of the usual 
therapeutic measures so carelessly ; or again the doctor in the resort to 
whom the patient has been entrusted, has also believed too much in cli- 
mate and has only too often failed to remember that instruction and 
supervision are essential elements in a cure, so that he has not always 
given the case that teaching and control which he should have known 
was necessary. Such neglect on the part of those supposed to be es- 
pecially expert is inexcusable and with an advancing realization by the 
doctor of his responsibility should be a rarer and rarer occurrence. 
Thus, either left to guide their own cases in their ignorance or insuffi- 
ciently instructed and taught, too many cases have returned home, 
their trouble, it is true, arrested, but uninstructed and unfamiliar with 
the management of their future lives, which is the chief thing on which 
they must rely thereafter to prevent relapses. 

As to the second reason, the belief in the specific effect of climate 
has been responsible for the sending of many hopeless cases to resorts, 
who Gould not possibly expect any permanent results, and the occasional 
surprising arrests of a few such cases have only tended to keep up a 



306 NATIONAL ASSOCIATION FOR THE STUDY 

practice whose generally unfavorable outcome can but throw doubt on 
the whole method. 

As to the third reason, it is well known that when our profession 
takes up any new method of treatment we are apt at first to be carried 
away by our enthusiasm; and the open-air home treatment of tuber- 
culosis is no exception, for while the excellent chances it offers to those 
who cannot hope to get better conditions should always be dwelt upon, 
we should also not forget that the addition of climate to the effects of 
the open air cure is too valuable to be neglected where it can be had. 

We have too long regarded tuberculosis as an all but hopeless 
disease, too long trusted to climate without care as a panacea of myste- 
rious powers, so that when, as a result of a dissemination of information 
on the proper handling of such cases an improvement in the results of 
home treatment is inaugurated, we tend to run to the other extreme and 
to doubt our former deductions from years of careful clinical obser- 
vation. Let it in passing be remembered to the honor of climato- 
therapy that from the workers in this line (and especially from the hon- 
ored president of this Association) have largely emanated the populari- 
zation of the hygienic and dietetic cure which is now so widely accepted 
and which is doing so much good, and it is largely these patients sent 
back from resorts where they have been faithfully and carefully trained, 
who have carried among the laity the gospel of fresh air and hope, and 
who have showed how much could be accomplished even in their own 
homes, and that even in our smoky cities outdoor life was possible and 
desirable ; that night air was harmless ; that open windows did not give 
pneumonia and that hygiene and common sense could save many who 
could not get the purer and more vitahzing air of our resorts. 

A great difficulty that meets us in the study of the subject comes 
from the fact that our opinions have been built on the clinical experience 
of the man working in this line and therefore are necessarily only the 
summation of innumerable personal impressions. Meteorology and 
climatology, much as they can help us, are not as yet, however, able to 
account entirely for the wonderful results which clinical experience 
has noted, just as the most skillful analysis of the waters of a mineral 
spring and the synthetic construction therefrom of an apparently identi- 
cal mixture fails to produce the results gotten by Nature's mixture. 

Necessarily experience and results must be relied on to give the 
final word and while that experience and those results are such as to 
allow the honest worker who has had them no doubt as to the power 



AND PREVENTION OF TUBERCULOSIS 307 

of climate, yet he must realize that the profession may doubt his im- 
partiality. 

But both in hopeless and in hopeful cases, however, the clinical 
evidence is too conclusive to admit of the doubt of the power of these 
more or less unclassified influences. In advanced cases the great 
amelioration or cessation of many of the most painful symptoms and 
the general improvement of the patient's comfort and strength, com- 
bined with the marked effect on mixed infections cannot be doubted, 
for they far surpass the very best results obtainable in similar advanced 
cases in our cities on porches or roof gardens, and the rapid relapses 
which in such advanced cases follow their return to ordinary climates 
are only another testimony in the same direction. Often, indeed, cases 
which on arrival appear to be utterly hopeless, patients who are brought 
on stretchers in the most desperate condition and whose course in their 
homes had been steadily downward, will, against one's best anticipa- 
tions, rally and regain a very fair state of health, which often can be 
continued for years provided they do not return to less favorable 
regions, and which it has only too often been proved is dependent on 
such a residence, for when tempted by an apparent complete arrest, 
they return home, the cured mixed infection soon lights up again and 
the rapid return of their trouble shows what the climate has been doing 
for them all the time. 

In cases of slight or medium severity the percentage of arrest of 
trouble as attested by many of our professions in their own persons 
and noted in many patients is fully as satisfactory as are the results 
of any of the therapeutic measures whether physical or pharmaceutical 
recognized as powerful in other diseases, and no more open to reason- 
able doubt. 

When we come to study the influences at^work in the matter let 
it be stated clearly that a specific influence of climate in tuberculosis 
such as that of mercury in syphilis or of quinine in malaria is no 
longer admitted, though the therapeutic influence of climate in this 
disease cannot be doubted and is as certain as are the effects of any 
of our standard drugs or other measures. 

Realizing then, as we do now, that the very first aim in the treat- 
ment of tuberculosis is and must always remain the raising of the vital- 
ity of the patient's system until it is able itself to conquer the disease. 
we see that the beneficial effect of climate depends upon its wonderful 
power in vitalizing the system, on its beneficial effects on metabolism. 



308 • NATIONAL ASSOCIATION FOR THE STUDY 

on its awakening of dormant or waning natural powers, and it is to 
this that we must look to explain its chief effects, and if it could be 
doubted for a moment that climate has such powers, then it might 
well indeed be questioned if there were any value in it. But that these 
are exactly the effects which it has been too satisfactorily proven by 
much careful scientific work to be questioned, and any one who has 
made a visit to any of our resorts, whether low or high, cannot have 
failed to note such effects in his own person. Its stimulating effect 
on all the vital processes, the deepening of respiration with the con- 
sequent improvement of gas interchange, the awakening of appetite, 
such as can be gotten by no drug, the improvement of the mental at- 
titude, all these are plainly in evidence. If this be so, and if it be also 
true that the whole aim of the hygienic and dietetic treatment is to 
produce such results, then nowhere can this treatment be expected 
to be so effectual as where it is aided by climate. 

No advanced workers in this line would to-day, as was formerly 
done, place climate first in the order of therapeutic measures. Let it 
never be forgotten that hygiene, diet, teaching and supervision must 
always come first, but granted that they are properly attended to, 
then enters the powerful role of climate, reinforcing and accentuating 
the effects of these other measures, and yielding results that cannot 
be approached even with the same care and watching and food in 
less favorable climate. 

Climate has been defined by Parke Weber as " a combination of 
various conditions of the atmosphere and earth's surface determining 
the suitability of a region or a site for the life and health of animals 
and plants " and climato-therapy as " the utilization of climate to 
promote comfort and recovery of the sick or to prevent the develop- 
ment of a disease." 

W. L. Dunn has also well said that " a climatic resort is a place 
where there is a maximum of sunshine, a minimum of fog and mist, 
relatively few hours of rainfall, a relatively low humidity, great purity 
of the atmosphere and an opportunity for efficient medical super- 
vision." Altitude is not referred to here despite its great value as not 
being a factor in all climates beneficial in tuberculosis. 

To discuss here the various forms of climate is not within our 
province, but it should rather be our effort to point out what in general 
are the effects which in climate have a beneficial influence. These 
can be classifed in the order of their importance as: first, abundance. 



AND PREVENTION OF TUBERCULOSIS 3O9 

and bacteriological and chemical purity of the air; second, sunshine; 
thirdj coolness, or, in a certain number of cases, warmth ; fourth, dry- 
ness, or in a few cases a moderate degree of humidity ; fifth, altitude ; 
sixth, wind; seventh, equability; eight, soil. 

The bacterial and chemical condition of the air has been carefully 
studied and has been found to vary from a very high pollution in the 
streets of our large cities to an almost absolute purity in high moun- 
tains, open seas, deserts and arctic regions, and is very low in country 
and mountain climates, especially when sparsely settled. 

Recalling the powerful role of streptococcal and other mixed in- 
fections in pulmonary tuberculosis and their power of changing a 
simple tuberculosis with chronic advance into a destructive consump- 
tion, noting also the bad effects of dusty atmospheres in producing 
bronchial catarrh, and especially the rapid lessening of mixed in- 
fections and such catarrhs in the purer air of our climatic resorts, 
the importance of this factor does not need to be further dwelt on. 
We would only here note that we believe it is chiefly due to the re- 
infection of the diseased lung by pus organisms and its irritation by 
dust, to which is often due the relapse of some cases when they return 
to city life. 

After pure air we would place sunshine and sun-heat, whose 
effects are both direct and indirect. Directly while its effects are 
evidently beneficial, they have never been completely analyzed and 
therefore will not be dwelt on here. The indirect effects of sunshine 
as seen in its powerful stimulation of the patients' spirits is of great 
importance. 

Dryness in most cases is a most important factor through its 
valuable anti-catarrhal effects, but when extreme this influence may 
be reversed and there are not a few cases in \yhich a moderate degree 
of humidity is more beneficial. 

Generally, low relative humidity with moderately low tempera- 
tures has a tonic effect and is beneficial in irritated conditions of the 
respiratory mucous membrane, while such low humidity with very low 
temperatures, while stimulating, is apt to irritate the mucous membrane. 
Low relative humidity with high temperature is generally debilitating. 
High relative humidity and moderate temperature are soothing to the 
irritated mucous membranes, but high humidity combined with low 
temperature favors catarrh. On the whole in pulmonary tuberculosis 
low relative humidity with moderately low, or low, temperature is 



3IO NATIONAL ASSOCIATION FOR THE STUDY 

most generally suitable and the average tubercular patient always 
makes his best gains in cold, dry weather, where such conditions 
prevail, but there are certain cases who do better with a high relative 
humidity and warm temperature. 

Equability in older people or in the very feeble can be of great 
value, but is not as important as used to be supposed. In stronger 
cases variations in temperature stimulate the vital activities, hence 
generally speaking, equability is not an important factor. 

Wind, when the patient is directly subjected to it is harmful, but 
when he is properly protected its purifying influence on the air, pro- 
vided vegetation is sufficient to prevent dust storms, is beneficial. 

Altitude. Most authorities are agreed that other things being 
equal some degree of altitude owing to the great purity of the air 
and to its stimulating effect on the metabolism and appetite, etc., 
is most desirable, but it is not here our function to discuss the large 
question that this opens up. Enough to say that care should be used 
to choose an altitude suited to the patient's degree of vitality and 
heart power. 

But a study of these local conditions and their adaptability to any 
given case is not enough. The temperament of the patient should be 
studied, as well as his docility and intelligence, for these play an im- 
portant part in getting the best results from a climatic cure. In a 
few homesickness can be so severe and unyielding as to make a de- 
parture from home impossible. Others are so intractable and so 
unwilling to obey any instructions that they are apt to injure them- 
selves by imprudences. 

Above all the financial condition of the patient is a determining 
factor, for, as one of your committee has elsewhere written, " If, 
however, one has to choose between treating patients in narrow cir- 
cumstances in their own homes or sending them to a resort where 
their poverty will not enable them to get the necessary conditions of 
quarters, diet and care, which are so essential, by all means let them 
stay at home. By changing their houses, by moving to the top floor, 
using the roof as an outdoor sun parlor, and spending the utmost 
possible part of their time there, by economizing in every other way 
in order to be able to spend more freely for good food and cookery, 
much can be done, provided always that their lives can be properly 
supervised. Where pecuniary reasons prevent the patient from seeking 
a special climate, excellent results can thus be had, though with greater 



AND PREVENTION OF TUBERCULOSIS 3II 

difficulty, in the patient's home, if the case is not too advanced and 
that home not too miserable." 

For the submerged tenth climato-therapy, save as supplied by 
the municipality or state, or philanthropic effort, is an impossibility 
and even the getting of proper conditions in their own homes is for 
them a Utopian idea. That municipal or state sanatoria have been 
opened for this class near our cities, but in localities where purer air 
and favorable conditions mark them as climatic resorts, gives hope 
in this direction, but the only permanent results among the poor will 
come from a prophylaxis based on teaching them decent modes of 
life, on improvement of bad sanitary conditions and on a change in 
the impossible hygiene of their lives. For those in modest or narrow 
circumstances it is only desirable when they will be able to get at the 
resort equal or better conditions than they could have at home. For 
those who are comfortably off, or for the well-to-do, it seems to your 
Committee that there cannot be a moment's doubt that any results 
that they could obtain at home by the most careful treatment, even 
if their home doctors are absolutely familiar with the kind of detailed 
and personal work which these cases require, can be infinitely im- 
proved and the percentage of cures or arrest greatly increased by the 
carrying out of similar treatment under the favorable influences of 
climate. 

We would here also say that with rare exceptions the patient who 
leaves the resort, however well he may be and however great the im- 
provement in his physical findings, should not be told that he is cured, 
but only that the process is arrested and that if when he returns home, 
he, by faithful living, can show for two years a continuance of such 
conditions, that then he may justifiably consider himself cured. 

A misunderstanding of this fact is lai;gely responsible for the 
popular condemnation of climatic cure. A climatic resort should be 
looked upon as a university where the patient goes to get under proper 
conditions that discipline and instruction which he will bring back 
with him into his daily life at home, where he should serve as a teacher 
of those with whom he is thrown, and the doctor in a climatic resort 
will be of use to his patient in proportion as he is able to be a forceful 
and stimulating teacher. 



312 NATIONAL ASSOCIATION FOR THE STUDV 



DISCUSSION OF THE REPORT OF THE COMMITTEE ON THE IN- 
FLUENCE OF CLIMATE IN PULMONARY TUBERCULOSIS 

Dr. Guy Hinsdale, Hot Springs, Va., moved the adoption of the 
report. 

Dr. L. F. Fhck, Philadelphia: I wish to record one vote in the 
negative and I have a good reason for objecting to the report. I cannot 
be accused of not having had personal experience or personal observa- 
tion. I wish to record myself as holding the opinion that there is abso- 
lutely nothing in climate in the treatment of tuberculosis. I began as a 
tubercular subject and took my initiation in nearly all the climates of this 
country, but my recovery was made more in Pennsylvania than in any 
other part of the country ; in fact it was not due to climate at all but 
to common sense way of living. I am convinced that it is a question 
of method and that that method can be successfully carried out in any 
climate. Some of my best results have been obtained in the slums of 
Philadelphia and some of my most serious losses have been in wealthy 
patients who have gone to seek climate ; they came back to die. I want 
to say moreover that I have had patients coming from Colorado, the 
West and the South to be treated in Pennsylvania and they have there 
been treated successfully where they had failed in the West and South. 
I can demonstrate that what I say is true and I repeat again that it is 
a question of method and open air but not climate. Proper living and 
the open air with proper diet and proper discipline will give the results 
and it remains for the climatologist to demonstrate that they can pro- 
duce results with climate that we cannot produce without it. As to the 
special places in the East, the Henry Phipps Institute has produced 
results that cannot be surpassed anywhere although it is devoted to the 
treatment of advanced cases. We have not only secured a restoration 
to physical health but this restoration has withstood the test of active 
life. I would not go on record in this matter at the present time were 
it not for the fact that the public may be misled in thinking that cli- 
mate is the most important factor. Three-fourths of the people who 
have tuberculosis cannot take advantage of climate and it is the busi- 
ness of this association to stand for those methods which will give 
health and encouragement to the vast majority. 

Dr. F. I. Knight, Boston : I wish to say a word for this Com- 
mittee who seem to be residents of health resorts and who may not 
care to back up the report that they have made. The suggestions are 



AND PREVENTION OF TUBERCULOSIS 3I3 

very moderate and it seems to me that they have found out that patients 
may be cured at h6me, particularly by sanatorium methods, but they 
are not inclined to think that sanatorium treatment at home will suf- 
fice for all cases. We feel very happy in the results that we get at 
home, but it has not yet been found out what can be done with sanato- 
rium treatment in different climates. We talk too much about the 
tuberculous. It is not the tuberculous ; it is the individual that we are 
treating, it is strange that the factors of climate should have no ef- 
fect upon the individual with tuberculosis when it certainly does have 
effect upon him when he has not tuberculosis. Surely climate has 
some effect on the patient as well as on the disease! We must spe- 
cialize our cases. It depends upon the condition of the patient as to 
where we shall put him and what we shall do with him. All of my 
early recoveries were in patients who were sent west and led lives 
about as at home. They went west and the climatic change probably 
did something for some of them. I feel like endorsing the report of 
the Committee as it is very mild. We should be rather stultifying our- 
selves to say that climate has no effect. 

Dr. B. F. Lyle, Cincinnati : I want to speak a word for the people 
who cannot go to the West as we certainly wish to hold out a ray of 
hope to these individuals. A great many of these people have been 
able to work and support their families after they had received the 
proper treatment, but the great trouble in the large cities is that we 
have nothing for these people to do even when they are much im- 
proved. The result is that they return to the city and to their usual 
method of living, which is soon followed by a return to the hospital. 
We can get good results in the city and there is no question about our 
doing good work. There are a great many persons who can be helped, 
who, if special climatic influence were necessary, could never get it. 

Dr. E. L. Stevens, Des Moines: It seems to me there is at least 
one point that has escaped the attention of the Committee. Several 
states have appointed commissions to investigate the wisdom of estab- 
lishing state sanatoria and these commissions have reported favorably 
in every case. Iowa is making such an investigation and if this report 
goes out unquestioned to our legislators it will damage whatever pos- 
sibility we may have of putting under proper treatment a large number 
of people who cannot go to any other climate. I hope the report will 
be modified in such a way that it will place less emphasis upon the ques- 
tion of climate. 



314 NATIONAL ASSOCIATION FOR THE STUDY 

Dr. P. M. Carrington, Fort Stanton: As a beneficiary of cli- 
mate, I must say a word. If for no other reason than the fact that we 
have from 325 to 340 days of the year when a man can live out of 
doors, one must admit that climate is important because you say a 
consumptive must live out. You cannot live out that many days of 
the year in this part of the country. There is a movement about to be 
established by the insurance orders of the country by which they ex- 
pect to be able to take care of at least 5,000 cases within two years. 
They claim that last year they paid out ten million dollars in death 
benefits for tuberculosis. If they had extended the lives of one half 
of these people for one year it would have been profitable. 

Dr. V. Y. Bowditch, Boston, asked to be put on record as approv- 
ing the report of the Committee. 

Dr. DeLancey Rochester, Buffalo: It is evident that the gentle- 
men do not understand the report, which I thought was very conserv- 
ative, as it lays stress upon the careful medical supervision of cases in 
sanatoria and gives them the most fresh air and sunshine which we all 
believe is the very best thing for them. At certain elevations some 
patients breathe better than in the cities, as the air is better than in the 
city and in those cases climate is an advantage. I live in the dampest 
and darkest city of the United States and yet I have had some patients 
recover even there. It is not, however, the place where I should elect 
to treat a case if I could send it anywhere else. 

Dr. Guy Hinsdale, Hot Springs: What would the members of 
the Association do if they had consumption? Would they go to the 
slums of a large city? No. They would seek the best climate they 
could get and they would not stay where cases of consumption were 
only sometimes cured. 

Dr. J. Solis Cohen, Philadelphia: I have had patients treated in 
all climates and there is no doubt in my mind but that, all other things 
being equal, patients that can afford to go to some other climate 
should do so. Many patients would get well when revivified by such 
a climate as that of the Adirondacks. 

Dr. E. R, Baldwin, Saranac Lake: We had no intention of pre- 
senting the claims of any particular climate or any particular treat- 
ment. We simply expressed the matter as we saw it. 

Dr. Alfred Meyer, New York: We all know the kindness of 
heart of the men who wrote this report, but it is not for a fight for 
any single class that we are organized. It is to fight out the truth as 
we see it. Like all human beings we are apt to be faulty. I wish to 



AND PREVENTION OF TUBERCULOSIS 315 

accentuate the particularly modest statements made by the Committee 
in favor of pure air. Dissension is a good thing and it is to the credit 
of the Committee that there was dissent. The fact that there was a 
difference of opinion is a good sign. We all want to accentuate the 
value of pure air. If patients are to be sent away they should be sent 
where they will still be under supervision. 

Dr. L. F. Flick, Philadelphia : I am actuated by judgment and not 
by sentiment. In the coldest climate, 365 days in the year may be 
lived out with advantage, never mind how severe or damp the weather, 
as it stimulates the desire for the very kind of food that is necessary 
for the treatment of the disease. I am satisfied that we can show very 
strong reasons for the belief that there is absolutely nothing in climate 
in the treatment of tuberculosis. I wish to go on record to this effect 
acting upon judgment and not upon sentiment. 

Dr. F. M. Pottenger, Los Angeles : I believe there is some value 
in climate but all specific measures are accentuated and overaccen- 
tuated. The treatment of tuberculosis is an individual effort and there 
is no specific climate. I consider the Committee's Report very fair. 
I do believe that the best treatment may be gotten where the patient 
can find a good physician and be surrounded by the best physical and 
mental conditions. For the person who cannot supply this with all the 
care of the home the problem is a very difficult one and the majority 
of cases must be cured at home. I know of some cases who could get 
well better at home than anywhere else, but we must use every means 
possible and climate is one of the best. 

Dr. W. F. R. Phillips, Washington: From the discussion I am 
satisfied that there is no agreement here as to the constituents of cli- 
mate. Some say you must go to Colorado and some say you must go 
somewhere else. Climate means more to one. than it does to another. 
For example, there is a climate in this room; climate means the aver- 
age physical condition of the atmosphere at a particular place and it 
differs everywhere. If we start to generalize we are going further 
than we have facts to substantiate. We pay tribute to climate every 
day of our lives. There is a meeting-line and a dividing-line. You 
cannot say where climate begins and where weather begins. The aver- 
age weather of the average place is the climate, but we are absolutely 
ignorant of what the climate really is. I would advise referring the 
report back to the Committee. 

It was moved and seconded that the report be adopted as read. 
Carried. 



THE INFLUENCE OF THE EVENT OF THE TUBER- 
CULOUS UPON NATIVE POPULATION 

By Charles Fox Gardiner^ M. D. 
Colorado Springs 



That my paper may be as useful and practical as possible to this 
Association, I have limited my work to include only the white native 
population at the open resorts of the United States (by open resorts 
meaning those resorts where the tuberculous mingle freely with the 
native inhabitants). 

The literature upon this subject of the danger of any community 
from infection caused by imported cases of tuberculosis, seems to show 
very clearly that when the tuberculous are treated in closed sanatoria, 
the death rate from non-imported tuberculosis among the native popu- 
lation is lowered, the influence of the closed sanatoria being in every 
case an educational one, instructing the natives how to avoid infection.* 
But in the open resorts of Europe some difference of opinion exists as 
to the relative danger of infection from visiting tuberculous invalids, 
and instances have been cited especially from Mentone and Nice, to 
show the danger from this source; while from the time of Bennet to 
the present, articles have mentioned these resorts as typical instances 
where infection was active.^ 

As I could obtain no reliable published reports upon this subject, 
I wrote a number of letters to several physicians in different open re- 
sorts in Europe. In reply, Dr. Holland, of San Moritz, writes me, 
March 3rd, 1905, that he is positive there has been no increase in tuber- 

*"Are Sanatoriums for Consumptives a Danger to the Neighborhood?" 
By S. A. Knopf, M. D., Med. Record, Oct 3d, 1896. — Comet, Nothnagel's En- 
cyclopedia, p. 274. — Dr. Edward A. Otis, Trans. A. C. Assn., 1896. — "A Plea 
for Moderation in our Statements Regarding the Contagiousness of Pulmonary 
Consumption." A. C. Assn., 1896, p. 48. Vincent Y. Bowditch, M. D. — Terri- 
torial Board of Health Reports, May, 1905. Chas. B. Cooper, M. D., Hawaii. 

* " Prophylaxis and Treatment of Pulmonary Tuberculosis." By S. A. 
Knopf, M. D., page 37. 

316 



NAT. ASS'n for study AND PREV. OF TUBERCULOSIS 317 

culosis among the native population due to tubercular invalids. The 
Courier for March, 1905, publishes a positive statement to the same 
effect. In a letter to me, Dr. E. Neumann states that there has been 
no infection of the native population (March 1905). Dr. William R. 
Huggard, of Davos Platz, also replies as above, while the official 
registers of the Davos Platz District (1876-1900) show that during 
the 25 years from 1876 to 1900 the total number of deaths from tuber- 
culosis among the native population of Davos was 38 persons, the total 
population in 1900 being 8334. This was the general opinion ex- 
pressed in a number of such letters received by me from open resorts 
in Europe and is decidedly at variance with the preconceived ideas 
generally expressed. Dr. F. M. Sandwith writes me from Cairo, 
Egypt (he is present at this meeting), " There is no evidence that tu- 
bercular invalids sent to Egypt have been a source of danger to the 
natives." From Clarmont, Cape Town, South Africa, Dr. Eyre writes 
me (March 21st, 1905), "The infection of native races by imported 
tuberculosis has been very marked, and this is especially the case in 
the more crowded centers of population." It must be remembered, 
however, that he is speaking of native races, and not the white man. 
He also says, " Yet when large labor gangs of pure Kaffirs are em- 
ployed in gold mines, harbor works, etc., the individuals comprising 
them then display the same tendency to infection." It is thus evident 
that even when native populations do not apparently come in contact 
with the tuberculous the result seems much the same, for crowding 
together in bad air is the main cause of tuberculosis, the proper soil for 
rapid growth being of more importance, apparently, than the quantity 
of seed sown. From many of the Pacific Islands^ we have reports 
showing how the natives succumb in large numbers to tuberculosis, and 
apparently such natives show little if any resistance, the disease gen- 
erally destroying life with a rapidity rarely seen among white races. 
Dr. Coleman has shown the lack of resistance in the negro, while I 
have myself seen striking instances of the lack of resistance among our 
Indians in Colorado, Wyoming and Utah, — not the civilized Indian 
who lives in a cabin, and is weakened by bad air, alcohol and syphilis, 
but the Indian hunter, living in the open air, with excess of proteid 
food. Even under such favorable conditions, and in an ideal climate, 

*"In the South Seas." By Robert Louis Stevenson (Page 28. Death). -- 
Samuel Cache, M. D., 1905, Buenos Ayres. " La Tuberculose dans la Republi- 
que Argentine." — " Phthisiology — Historical and Geographical." Evans, p. 56. 



3l8 NATIONAL ASSOCIATION FOR THE STUDY 

I have seen cases infected and die in two months, the racial resist- 
ance was so low. Hence, in estimating infection among savage, or 
semi-savage races, as a basis for comparative study, due caution has 
to be observed, since the native races have a lowered resistance, as 
compared to white races; and as the guinea-pig differs from the dog, 
so we differ from native races in physiological resistance to tuber- 
culosis. We have been subject to the law of selective elimination, and 
it is due to this law that tuberculosis has not only diminished among 
us, but it has also left those whose resistance is on a higher plane. 
While the native savage races are now undergoing the beginning of 
their evolution we are nearing the end of ours. Other diseases such 
as smallpox, measles, etc., show the working out of the same general 
law in the case of civilized man and his dark-colored brothers.^ 

The closed sanatorium for the tuberculous in the United States 
has the same influence in lowering the non-imported tubercular death 
rate as it has been found to have in Europe.^ It is, however, the so- 
called open resorts for the tuberculous in the United States (the many 
villages or cities located all over our country in favorable climatic 
situations), that should repay our study as to the influence the event 
of the tuberculous has upon native populations. It is in such places 
in our country that the danger would seem to be urgent, since the con- 
ditions are apparently ideal for infection. The resident population, as 
a class, has shown a susceptibility to tuberculosis, many families having 
lost some member by the disease, for while it may be true that a tu- 
bercular parentage induces a certain resistance in the offspring, it is 
equally true that tuberculosis appearing in a brother or sister indicates 
a lower plane of resistance among the other children of that family. 

It is a well known fact that in the average open resort of the 
United States, the precautions against infection from dried sputa are 
wofuUy inadequate, and with few exceptions there are no laws en- 
forced for the disinfection of rooms, eating utensils or soiled clothes, 
even when the consumptive invalid lives in close and indiscriminate 
contact with the non-tubercular, in boarding-houses, hotels, public 
buildings, etc. In addition to this the tuberculous frequently marry, 
one or both parties of this union being tuberculous, and they have 
children who are " under fire " from tubercular germs from birth. 

^ Vtrchow's Archives, May, 1900. 

*"The Sanatorium, or Closed Treatment of Phthisis." A. C. Assn., 1896, 
p. 30. Edward A. Otis, M. D. 



AND PREVENTION OF TUBERCULOSIS 319 

The population of most of these open resorts in our country has 
increased rapidly during the last ten years; the industrial indoor oc- 
cupations have in many cases increased at a similar rate, both factors 
predisposing to the extension of tuberculosis; and if what we have 
been taught is true, namely, the number of tubercle bacilli from dried 
sputa in the air is a criterion of its infectiousness, certainly the air in 
our health resorts must have an excess of these germs and be cor- 
respondingly dangerous to the non-tubercular inhabitant. Therefore, 
it has seemed to me that on purely theoretical grounds, the danger 
from tubercular infection at these open resorts could not fail to be a 
serious one, and any investigations on a scientific basis could but con- 
firm this theory. To obtain any reliable data upon this special subject 
is a very difficult matter, and as there are no statistics published cover- 
ing a field broad enough for comparative study, I have been forced to 
obtain what I could by circulars and personal letters. I have there- 
fore sent circular letters to several physicians in each resort, men 
whose experience and judgment warranted careful and accurate an- 
swers, and in addition I wrote personal letters also when the circular 
letter seemed to be deficient in detail. The prompt and generous 
response to practically all letters sent by me was most gratifying, and 
showed the interest taken in the subject. I wish now to thank the 
writers publicly and acknowledge my indebtedness to them. The 
questions were as follows : 

1. Among your native population have you known of any cases of tuber- 
culosis contracted from your imported tubercular invalids? 

2. In your opinion, have tubercular invalids sent to your locality been a 
source of danger to your native population? 

3. Has your non-imported tubercular death rate increased since the event 
of tubercular invalids coming to your locality? 

4. Have indoor industrial occupations become more frequent in your 
locality than formerly? 

5. Do you have any law enforced regarding t"he disposal of expectoration 
from tubercular invalids? 

6. Are rooms inhabited by sick invalids disinfected? 

I had answers from resorts in Massachusetts, Connecticut, New 
York, North and South Carolina, Virginia, Georgia, Texas, New 
Mexico, Arizona, Utah, Colorado and California. With very few ex- 
ceptions the answers may be summed up as follows: while it was 
thought that the imported cases of tuberculosis might be a danger to 
the native inhabitant, most of the men had never seen a case of infec- 
tion from this source, and the general opinion (about 90%) was that 



320 NATIONAL ASSOCIATION FOR THE STUDY 

the danger was much exaggerated, that after years of practice they 
had never seen a case so infected, and the danger in theory and fact 
differed materially. In regard to increased death rate from non-im- 
ported tuberculosis there were no figures available. Indoor industrial 
occupations had increased in the average resort, and with few excep- 
tions no laws, regarding the disposal of tubercular sputum or disin- 
fection of rooms, were enforced. 

The replies from all these physicians practising at our open 
health resorts were in the main the same; that is, all agreed that the 
imported tubercular invalid was of no danger to the native population 
as far as could be observed by them after many years in active practice. 
This opinion is certainly at variance with all established theories. How 
do we account for this? Of course it can be objected that I have col- 
lected personal opinions only with no accurate statistics, and that in 
this way personal prejudice, carelessness in answering questions, etc., 
might have made the reports collected by me in this manner of slight 
value, or as Cornet has skeptically expressed it, " Natives in admitting 
cases of infection thereby imperil their most precious interests." Be 
this as it may, these reports I have collected this year of the non-oc- 
currence of infection, or its marked infrequency, at our open health 
resorts, do not stand alone in what I show in this paper. Other scien- 
tific work has been done in the past regarding two of our resorts. Dr. 
E. R. Baldwin^ has, in a paper read in 1900, shown very conclu- 
sively that the danger from infection at Saranac Lake, New York (a 
town of 2,000 inhabitants) is very small. He also writes me on March 
loth, 1905, " I am glad to say the experience up to date does not 
change the conclusions arrived at by me in 1900." Of course at 
Saranac Lake the conditions are unusual. The personnel of the physi- 
cians and the object lesson of the Sanatorium count for much, but there 
must be many cases of exposure of susceptible individuals to the germs 
of consumption, enough to warrant, from a theoretical standpoint, 
more cases than twenty infected in fifteen years. Probably most towns 
of 2,000 inhabitants in the United States show as many non-imported 
cases in fifteen years — towns which have no reputations as health 
resorts, and where the tuberculous rarely if ever come as health-seekers, 
and infection from invalid sources is therefore rarely a possibility. 

If I may be pardoned for referring to my own work on this sub- 

* " The Conditioir; of Tuberculous Infection and Their Control." Yale 
Med. Journal, March, 1900. 



AND PREVENTION OF TUBERCULOSIS 32 1 

ject, I can say for Colorado Springs (an open resort in Colorado), 
that the danger from infection in proportion to population seems to 
be even less than at Saranac Lake. In 1892, after several years of 
careful investigation, I reported only ten cases of non-imported tuber- 
culosis occurring in fifteen years, the population at that time being 
about 15,000,^ again in 1897 I reported, to the Climatological Associa- 
tion, the result of a systematic search for all cases originating in Colo- 
rado Springs, and the total number in twenty years was twenty cases f 
so that for Colorada Springs I have since 1889 neglected no opportu- 
nity to collect a list of all cases of non-imported tuberculosis occurring 
among the resident population or visitors. I have been aided in this 
by the physicians who are themselves interested in the subject, and our 
different health officers have also done all in their power to trace and 
report such cases to me. The result of this investigation has shown 
that at Colorado Springs, with a population of from 15,000 to 30,000, 
there has been but one case each year originating among the native 
population, or sixteen cases of pulmonary tuberculosis in sixteen years 
occurring there, that were not tuberculous when they arrived, although 
some of these cases had been away at the seashore and other places on 
prolonged visits and may have been infected before coming to Colorado. 
I have no record of other forms than pulmonary, but meningeal, glan- 
dular, or bone tuberculosis, is not more frequent than in any other 
places, although a large proportion of our children have a tubercular 
parentage, and precautions against infection are not enforced to any 
extent.^ 

^ The American Journal of Medical Sciences, 1892, C. F. Gardiner, M. D. 

* " The Dangers of Tubercular Infection and Their Partial Arrest by Cli- 
matic Influences." Trans. A. C. Assn., 1897. C. F. Gardiner, M. D. 

' " Growth and Development of Children in Colorado." By C. F. Gardiner, 
M. D., and Henry W. Hoagland, M. D. Trans. A. C. Assn., 1903. — " Re- 
searches on Tuberculosis," 1897, pp. 7-8. Austin Ransome, M. D. — " What In- 
ferences May be Drawn from Cases of Pulmonary Tuberculosis Reported to 
Have Originated in Colorado? " Boston Surgical & Medical Journal, Oct., 1897. 
S. G. Bonney, M. D. — " The Influence of High Altitudes upon Heredity in 
Tuberculosis and Its Effect upon Some Forms Other than Pulmonary." Clima- 
tologist, June, 1892. H. B. Moore, M. D. — "A Study in Heredity in Its Re- 
lation to Immunity and Selective Activity in Tuberculosis." Medical Record, 
Oct. I2th, 1901. Herbert Maxon King, M. D. — "The Modern Treatment of 
Pulmonary Tuberculosis." Medical Record, Nov. 17th, 1900. Earl Sprague 
Bullock, Surgeon, U. S. A. — " Channels of Infection in Tuberculosis." Hugh 
Walsham, M. D., p. 113. — "Diagnosis and Modern Treatment of Pulmonary 
Consumption." Arthur Latham, M. D., p. 65. — " Environment in Its Relation 
to the Progress of Bacterial Invasion in Tuberculosis." American Journal of 
Medical Sciences, E. L. Trudeau. — Journal of Infectious Diseases, March i, 1905. 
F. Harbity, M. D. — " Tuberculosis and Acute General Miliary Tuberculosis." 
By Prof. D. G. Cornet, p. 254. 



Z^.^ NATIONAL ASSOCIATION FOR THE STUDY 

It has seemed to me rather remarkable that from about every open 
health resort in the United States that receives the tuberculous, and 
where large numbers of such invalids have been living for years among 
the native population, the reports all show that the infection has been 
limited to such a degree. It is certainly a striking fact that from these 
resorts the average rate of cases per population is considerably less 
than in many towns or cities where there are very few tuberculous in- 
valids. Health resorts, therefore, from all reports that I can gather, 
are less dangerous from an infectious standpoint than the average 
towns in the United States, and if these records are correct, either in- 
fection is a myth, or some factor is at work in these open resorts for 
the tuberculous, that modifies the infection from this disease. It is 
probable that several causes contribute to this evident restriction of 
infection at these resorts. In the first place we are apt to ascribe en- 
tirely too rapid an action to this infection from tuberculosis. We now 
know that the moment of actual infection with the tubercle bacilli is 
often far removed from subsequent symptoms that call the attention 
of patient or physician. Tuberculosis is so often slow and insidious 
in its action, and its latency, without any noticeable symptoms, 
is, I believe, far more common than is generally known, and our im- 
patience to ascribe a recent cause when a developed case is seen, fre- 
quently clouds our judgment as to the time of real invasion. I have 
frequently seen cases reported as due to recent infection when careful 
inquiry disclosed the fact that the disease in a more or less latent form, 
had been invading the tissue for years ; perhaps since childhood, when 
from tonsil to lymphatics it had been slowly working its way, without 
any disturbance of the general health, until some depressing factor de- 
termined the sudden activity that reacts through the whole body. Such 
cases are often classed as reinfected from outside the body. In aver- 
age health resorts these depressing factors among the permanent in- 
habitants operating as open doors to tubercular extension, or renewed 
activity, are probably not as prevalent as elsewhere, and therefore latent 
or undiscovered tuberculosis is less apt to be aroused to activity in 
these places. While the individuals comprising the permanent popula- 
tion of our open resorts are no doubt exposed to tubercular germs more 
frequently than the inhabitants of our average villages, or even cities, 
at the same time the individual resistance is better. The climate has 
more available sunshine, the soil is drier, indoor occupations compara- 
tively infrequent, the food is superior, and, above all, the crowding of 



AND PREVENTION OF TUBERCULOSIS 323 

the tenement dwellers in bad air is largely avoided. Then too, there is 
no doubt that, although knowledge regarding the laws governing the 
extension of tuberculosis is decidedly lacking among most people, it is 
probably true that the permanent inhabitants of our health resorts are, 
as a class, becoming every day more and more alive to the dangers from 
this disease, and, from direct observation are, in a general way, be- 
coming trained to note the advantages of efficient ventilation. 

In fact my records go to show that the natives of open resorts for 
the tuberculous are in a better physiological condition to resist tuber- 
cular infection than the average inhabitants of other towns and cities; 
and all the facts seem to prove that it is better to be daily exposed 
for years to the germs from the tuberculous in a superior climate, than 
not to be so frequently exposed but to be under the influence of bad 
air and overcrowding in an unfavorable climate ; that the event of the 
tuberculous among the dwellers in our resorts is not as dangerous a 
factor as it has been supposed to be ; and that the lesson to be drawn 
from this is to increase human resistance by proper ventilation day and 
night, and then the dreaded germ that causes consumption will lose 
its power to infect mankind or destroy life. 

DISCUSSION ON DR. GARDINER'S PAPER 

Dr. DeLancey Rochester, Buffalo : I should be very glad if some 
one could give us some statistics in regard to the city of Denver in this 
respect. 

Dr. L. F. Flick, Philadelphia: As to the non-appearance of tu- 
berculosis in the native population in places which have been invaded 
by the tuberculous, I am inclined to think that perhaps the immunity 
that is enjoyed by the descendants of consumptives may have some- 
thing to do with the lower death-rate. Children are more immune than 
the parents, and if this is true then the children of consumptives are 
less susceptible than the parents were. Here, perhaps, we have one 
explanation of why there should not be in a population like Denver, as 
many cases of tuberculosis as one might expect. 

Dr. J. W. Kime, Fort Dodge, here read a letter printed in a recent 
issue of the Journal of the American Medical Association relating to 
the effect of tuberculosis on the native population in Los Angeles. 

Dr. C. F. Gardiner, Colorado Springs: Replying to Dr. Roch- 
ester's inquiry, I would state that our Chairman (Dr. Bonney) has done 



324 NAT. ASS N FOR STUDY AND PREV. OF TUBERCULOSIS 

very good work in collecting statistics concerning tuberculosis in the 
native population of Denver, but the reports seem to vary very much. 

As to the article read by Dr. Kime, I might mention that Dr. Ed- 
wards of San Diego wrote recently that only four or five cases had oc- 
curred among the native population of about 180,000 inhabitants. 

Dr. F. M. Pottenger, Los Angeles : Two cases have occurred in 
about ten years in Los Angeles so far as can be learned. The statis- 
tics given in the letter just read by Dr. Kime have been kept up for the 
purpose of calling attention to what might happen if tubercular cases 
herded together in cheap lodging-houses. Los Angeles does not fear 
an imported population, as we can have no great amount of tubercular 
infection of our population by these cases. 



SYMPOSIUM 

ON 

SANATORIUM TREATMENT OF CONSUMPTION 



SANATORIUM PROVISION WITH INDUSTRIAL OP- 
PORTUNITIES FOR INDIGENT CONSUMPTIVES 

By Herbert Maxon King, M. D., and Henry B, Neagle, M. D. 

Liberty, N. Y. 



The narrow limitations in the way of remunerative employment 
which must necessarily be imposed upon the consumptive whose disease 
is not thoroughly arrested, make the problem of his self-maintenance 
during treatment a difficult — not to say serious — one. 

Exertion, either physical or mental, if not wholly proscribed, must 
be permitted only with the greatest degree of moderation, and under 
most careful supervision, if harm to the patient is to be avoided. The 
disastrous results of overexertion or emotional excitement on the 
part of tuberculous invalids with unarrested lesions, are familiar to 
every physician. 

Thus the list of possible occupations open to the consumptive 
during the active stages of his disease is a veVy small one, and the in- 
stitution, therefore, which has for its object primarily the arrest and 
cure of the disease, and secondarily the self-support, in whole or in 
part, of the patient during treatment, is assuming at the start a rather 
paradoxical role. That the difficulties in the case are real and often 
insurmountable, is evidenced by the failure of several institutions of 
this character to survive, although in some instances ample influence 
and financial support were not lacking. Our inquiries among those 
which are still in operation, in America at least, have not resulted in 
reassuring reports, as will appear presently. 

32s 



3^6 NATIONAL ASSOCIATION FOR THE STUDY 

On the other hand, that the patient whose disease is quiescent or 
partially under arrest, may under certain conditions (which pertain 
chiefly to climate and intelligent supervision) safely undertake light 
occupation is undoubtedly true. 

It is, indeed, probable that among the chief reasons why these 
institutions have not so far met with greater success are: first, 
that the industrial limitations to which a tuberculous patient is neces- 
sarily subject have not been fully recognized by the promoters, and 
second, that no adequate provision has been made for the preliminary 
care and education of the patients during the active stage of the disease. 

Most of the closed sanatoria now in existence were designed 
solely for the curative treatment of tuberculosis, and even those pur- 
posing to reach the working classes pretended to little more than the 
hygienic education of the patients with the arrest of their disease. 

It is difficult to alter the original purposes of such an institution 
at a period more or less remote from that of its establishment, except 
by adding to it new and separate units, and, in most instances, this 
has been impracticable owing to the lack of space and various other 
limitations. In fact, it has been almost universally true that the 
problem of finding ways and means to maintain the original design 
of such sanatoria has been quite sufficient for the trustees and man- 
agers, without encumbering themselves with expensive experimental 
innovations. When industrial features have been introduced into 
previously existing sanatoria, therefore, it has been, as a rule, in a 
dilettante sort of way, and usually without a well thought-out plan 
and sufficient funds to insure success. 

It is so easy to speculate on the results which could be obtained, 
theoretically at least, in the ideal sanatorium with provision for in- 
dustrial features, that the wonder of it is the public press, ever seeking 
sensational matter along the lines of tuberculosis, has not long ago 
exploited the idea. 

Such an institution, let us say, should consist of three main divi- 
sions — infirmary, pavilion and industrial department, the first two 
forming complete units each, the last divided into as many distinct 
units as there are branches of industries undertaken. For instance, 
agriculture in its various branches; stock-raising, including poultry 
farming, bee culture, etc. ; certain manufacturing industries, and the 
administration of the institution itself in its various phases. 

The new candidate for admission to such a sanatorium is, of 



AND PREVENTION OF TUBERCULOSIS 327 

course, first taken into the infirmary. Here he is kept during the 
active stage of his disease (or until he is found to be an unsuitable 
case and discharged) and is given that medical supervision, care, 
nursing and instruction so essential to a successful result. When his 
disease is quiescent, his temperature and vi^eight normal, and his con- 
dition otherwise permits, he is transferred to a pavilion where, under 
close observation, suitable exercise tests are made. These tests deter- 
mine his physical qualifications for work of any kind, as well as to 
which branch of the several industries, at the command of the sana- 
torium, he is best adopted by his individual peculiarities, physical and 
mental. As his disease is arrested, his exercise is directed into those 
industries for which he seems best fitted, and again he is transferred 
to one or another of the units of the industrial department. Finally, 
he is sent back into the world with restored health and a new vocation 
to resume his place among breadwinners. 

Some such plan has, no doubt, occurred to the mind of every 
physician and humanitarian who has made himself familiar with the 
difficult problems, medical and sociological, which tuberculosis sug- 
gests. Such a plan, however, to present much prospect of success, 
must possess greater resources than are usually available for innova- 
tions of this character. 

The original cost of the plant would exceed what can ordinarily 
be obtained with difficulty, for old and tried philanthropies, and for 
several years at least, the cost of administration, which could not but 
reach somewhat startling figures, would have to be provided for else- 
where than from the earnings of such an institution. The plan would, 
after all, appear in the light of an experiment with at least a consider- 
able chance of failure, and thus the difficulties in securing the neces- 
sary funds to begin with, must be apparent. ^ 

Only a few days ago there appeared in the columns of one of the 
New York dailies an account of a proposed plan to establish on a huge 
scale what might be termed an industrial community for tuberculous 
invalids, near Las Vegas, in New Mexico. According to this report, 
the proposed plan is purely philanthropic in object, and, to start with, 
has an equipment in lands and buildings so vast that, taken together 
with the colossal extent of the work proposed and the number of 
patients which it is expected to care for (from five to twenty-five 
thousand), those of us who have experienced the vicissitudes and 
difficulties incident to more modest establishments may be pardoned 



328 NATIONAL ASSOCIATION FOR THE STUDY 

for entertaining some skepticism as to its eventual success. Never- 
theless it is conceivable that even such an immense institution, if 
properly organized into compact and scientifically administered units, 
and the whole wisely and judiciously governed by a board of dis- 
interested and competently trained officers, may open a new and 
brilliant chapter in phthisiotherapeutics, especially as applied to the 
consumptive poor. 

With the idea of ascertaining the degree of success attained thus 
far in attempting to provide employment for consumptives, a number of 
circular letters were sent to the institutions in this country and Canada 
known to be thus engaged. The following questions were asked: 

(i) Number of cases furnished with employment? (2) Character 
of employment? (3) Number of cases reporting or observed after- 
ward? (4) General relative condition of such patients as regards 
weight, fever, cough, expectoration, etc., in comparison with previous 
condition? (5) List of suitable occupations? (6) General informa- 
tion as to the practicability and economy of the plan ? 

The replies were characterized principally by their uniformity, 
and while all stated that the work was as yet in an incipient stage, 
there was a rather disheartening unanimity in the admission of failures 
thus far. 

Considering the subject purely from the standpoint of economy, 
as one physician of very considerable experience tersely puts it, " the 
slight saving in service scarcely compensates for the extra trouble of 
supervising the very irregular work obtained." On the other hand, 
there is a very general admission of the fact that some employment is, 
in many cases, not only possible, but even advisable. 

The difficulty of obtaining accurate statistics is dependent largely 
upon the fact that the work is, as yet, in its most experimental stage, 
but it is apparent that individual variation renders judgment as to 
capacity for work as fallacious as it is in the whole matter of progno- 
sis. Institutions established with the idea of permitting patients to 
support themselves and their families by their own exertions, while 
enjoying the benefits of open-air treatment under excellent climatic 
conditions, however well managed and however generously endowed, 
have proven failures one and all. On the other hand, under the most 
unhygienic conditions and in the face of almost insurmountable dif- 
ficulties, most gratifying results have been attained in individual cases 
by workers in the free clinics of our larger cities. 



AND PREVENTION OF TUBERCULOSIS 329 

Much of the discrepancy in the results of the work accompHshed 
by physicians in charge of sanatoria and those in private practice, is 
due, doubtless, to the fact that the standards of judgment must neces- 
sarily vary in a marked degree. On the one hand, we have the most 
careful supervision actuated by the desire to obtain statistical results 
comparable to those of competitors ; on the other, actual necessity com- 
pelling too short a time limit to the treatment recommended as most 
efficacious. 

In striking contrast to the discouraging reports of the philan- 
thropic institutions so far in the field, is the analysis of the histories 
of patients admitted to the Loomis Sanatorium. Of fifty cases taken 
at random, and consisting of both early and advanced cases, the average 
duration of the disease at the time of admission was over three years, 
and during these three years 70 per cent, had been self-supporting. 
Still more striking is the fact that, in the case of twenty-five advanced 
cases, with fibrosis predominating, the average duration was five years, 
and during these five years 68 per cent, had been self-supporting. 

With a view of determining the relative merits of complete rest 
and gradually increasing exercise in quiescent cases, some experiments 
were carried out at the Loomis Sanatorium Annex during the autumn 
of 1902. The results were interesting as bearing upon the present 
question. " Twenty patients, all with quiescent lesions, without rise in 
temperature, and up to, or a little above, normal weight, were selected 
and divided into two classes of ten patients each, known as Class A 
and Class B, respectively. In Class A there were five men and five 
women. ... In Class B there were six men and four women. The 
experiment consisted in placing Class A on greatly increased exer- 
cise (hill climbing) for a period of two weeks, during which time Class 
B was upon a regime of enforced rest. The following two weeks the 
conditions were exactly reversed. Class B taking the increased exercise 
and Class A the enforced rest. Observations were made of pulse and 
temperature for one week prior to the rest, during the test, and for a 
week following the test. Changes in weight were recorded under the 
various conditions, as were the effects produced upon cough and ex- 
pectoration." 

Passing over the details of the experimental test, the following 
tables show the summary of results in the two classes : 



330 



NATIONAL ASSOCIATION FOR THE STUDY 



Summary — Class A. 


Exercise 
T. P. 


Rest 
T. P. 


Weekly average temperature and pulse prior to tests 
Weekly average temperature and pulse during tests . . 
Weekly average temperature and pulse after tests . . . 


98.5 93 
98.3 96 
98.3 89 


98.4 86 

98.5 96 

98.6 95 


Total number of pounds gain in weight 

Total number of pounds loss in weight 

f Increased 


Period of 
increased 
exercise. 

I4| 

I 

6 

4 

2 
6 
3 


Period of 
enforced 

rest. 
l6i 

1 


_, , Absent 


2 


Cough^ Decreased 

Stationary 


5 
I 


C Increased 




„ ^ ,. Stationarv 


3 
3 
2 


Expectoration^ Decreased .....:::: 


Absent 







Summary— Class B. 


Rest 
T. P. 


- Exercise 
T. P. 


Weekly average temperature and pulse prior to tests 
Weekly average temperature and pulse during tests . . 
Weekly average temperature and pulse after tests . . . 


99.3 100 

98.3 too 

98.4 96 


98.4 96 
98.6 100 
98.6 102 


Total number of pounds gain in weight 

Total number of pounds loss in weight 

C Increased 


Period of 
enforced 

Rest. 
26 

I 
2 

4 
4 

3 
4 
2 
I 


Period of 
increased 
exercise. 

13J 

3 
3 

4 


^ , Stationarv 


Cough^ Decreased 


Absent 


r Increased 


4 
2 


T^ . Stationarv 


Expectoration^ j5^^^\^ J [ [ \ \ ] [ ] [ 


3 
I 


Absent 







From the latter it will be seen that the average maximum weekly 
temperature actually fell during and following the test in both classes, 
while even the pulse was not materially affected. With the weight 
there was a small balance in favor of the period of enforced rest in both 
classes, but it must be remembered in this connection that most of 
these patients were above normal weight before the experiment was 
undertaken. In Class A, during the period of increased exercise, there 



AND PREVENTION OF TUBERCULOSIS 33 1 

was a total gain in weight of 14^ pounds and a total loss of 2% 
pounds, while during the subsequent period of enforced rest there was 
a total gain of i6>^ pounds and a loss of 5^ pound. In Class B, during 
the period of exercise, there was a total gain of 13^/^ pounds and a loss 
of 2 pounds, whereas during the antecedent period of rest there was a 
total gain of 26 pounds and a loss of i pound. The effect of the ex- 
periment upon the symptoms may be gathered from the tables. It is 
worthy of remark, however, that in every instance the patients felt 
better during the period of increased exercise. 

Following these exercise experiments in the autumn of 1902, an 
attempt was made at the Annex of the Loomis Sanatorium to organize 
a working corps of quiescent cases among the men. 

The work available at the time consisted of certain kinds of farm 
labor : caring for live stock and improving the walks and wagon roads 
(chopping wood was attempted, but abandoned because of its bad 
effects upon patients). Remuneration was offered sufficient to enable 
a patient nearly to meet his expenses by working four hours per day, 
divided into from two to four shifts. Fifteen men were selected as 
physically able, and permitted to work from one to six hours per day, 
each. The novelty waned, however, and, within the month, there was 
scarcely an applicant, although no harmful effects had followed in any 
case. The plan had to be abandoned for lack of inclination on the part 
of the patients. 

This spring a slightly different plan is being tried as an experi- 
ment. A moderately large garden plot is turned over to one of the 
patients of exceptional intelligence and some executive ability, who is 
to organize his working corps among the patients on a cooperative 
basis. All expense is to be borne by these patients, who, of course, 
will furnish among themselves the necessai:y labor, all to be under 
close medical surveillance. The entire product of the garden, the sana- 
torium agrees to purchase at market prices. So far the interest and 
enthusiasm in this plan are apparently more substantial than was the 
case under former conditions, possibly because of the element of 
chance in the result, or, perhaps, because of the independent phase 
which the scheme presents. 

It is apparent from the experimental work quoted that moderate 
exercise, carefully supervised, may prove not only permissible but bene- 
ficial in certain cases, and this is substantiated by reports from in- 
stitutions having some years of actual experience in providing such 



332 NAT. ASS N FOR STUDY AND PREV. OF TUBERCULOSIS 

exercise. Moreover, consumptives not only can, but actually do re- 
main, productive agents for many years after the appearance of the 
disease. It is equally true, however, that every attempt thus far to 
organize even moderately large numbers of phthisical patients into 
self-supporting communities has been uniformly unsuccessful. 

The obvious conclusions drawn from what we have learned in the 
course of our own experience, and as a result of our inquiries, are: 
first, a sanatorium should be upon a sound financial basis, inde- 
pendent of its earning capacity, before entering industrial fields. It 
cannot safely rely upon financial returns from its industrial features, 
since the latter are fully as apt to increase as to decrease the expense 
of administration; second, if industrial features are to be introduced, 
as wide a range of occupations as possible should be at command, in 
order to meet individual requirements in both sexes, and suitable pro- 
vision should be made for permitting very light work and short hours 
to start with in all cases. 

It is scarcely necessary to add that no patient should be permitted 
to do work of any kind until sufficient time has elapsed after his ad- 
mission to establish his physical ability. Medical supervision should 
be unremitting throughout his sanatorium residence, and allowance in 
time limit of residence should be made for the relapses which will 
inevitably occur wherever any great number of consumptives is 
employed. 



DETENTION INSTITUTIONS FOR IGNORANT AND 
VJCIOUS CONSUMPTIVES 

By John P. C. Foster, M. D. 
New Haven 



The movement to arrest the spread of tuberculosis and so far as 
possible eliminate it cannot be successfully prosecuted until the de- 
tention of indigent consumptives is lawful and is systematically en- 
forced. The right to detain a consumptive in a hospital at the discretion 
of the health officers is not to be confined to those who seek public 
aid because of their inability to continue work. There are cases that 
are at work and may continue to be at work for an indefinite period 
which should be removed to detention institutions and retained there 
as long as the authorities may deem advisable. I am fully aware that 
if such measures are adopted they will for a time call forth a flood of 
sentimentalism and test the courage of those who make the effort to 
enforce them. This will be found especially true in the smaller com- 
munities where all such measures must come more readily into public 
notice. The interest, however, of the vast majority must in the end 
prevail, and detention institutions will ultimately be accepted without 
criticism. 

In discussing the detention in institutions of cases of tuberculosis 
that have become a public charge, it would be manifestly improper not 
to draw a distinction between those cases that are ignorant and those 
that are vicious. 

The word ignorant as applied to the first class of consumptives 
is unfortunately chosen. It seems to imply ignorance of the nature 
of the disease and of the proper sanitary precautions demanded of 
them. A discussion in this Society as to the proper disposal of 
ignorant patients seems to be as inappropriate as would be a discus- 
sion in a teachers' convention as to what should be done with ignorant 
children. Ignorance is not excusable, and where it exists the fault 

333 



334 NATIONAL ASSOCIATION FOR THE STUDY 

does not rest with the patient. In communities of average size there 
are comparatively few famihes in which a fair degree of cleanliness 
cannot be secured by systematic inspection. My daily experience 
leads me to believe that the efforts to instruct the general public as 
to the care of infectious material have led to a very remarkable under- 
standing of the question even among the poorest classes. The chief 
obstacle to the proper care of the tuberculous in such families is 
poverty. In large cities the extreme crowding of the tenements 
creates a special condition. Patients who may be fully informed as 
to the proper care of themselves are unable to comply with even the 
simplest regulations. We thus find a very large class not ignorant, 
not vicious, anxious to do all in their power to obey instructions, but 
simply unable to do so by reason of poverty and the overcrowding 
that poverty renders unavoidable. These sufferers, whom I would 
prefer to style the unfortunate, constitute the first group for our 
consideration. 

If work among this class of unfortunates is to be of permanent 
value, it is essential that all cases of tuberculosis, as soon as the 
character of the disease is determined, should be reported to the 
health officer. Opposition to enforced reports of tuberculosis is still 
very strong upon the part of a large number of practicing physicians. 
This opposition is due largely to an imperfect understanding of the 
purpose of those who advocate registration. The experience in New 
York City has clearly demonstrated the advisability of the law, and 
also shows how quickly professional opposition will yield before a 
determined effort combined with good judgment. When all known 
cases of tuberculosis are a matter of record, those cases that are 
properly classed as unfortunate should be kept under the observation of 
district inspectors, and the progress of the disease and the physical 
and moral status of the patient be made a matter of record. All 
cases should be allowed to remain at large as long as they are com- 
fortably supported and are careful to obey the rules that are furnished 
them by the inspectors. Any case that has become helpless and has 
been thrown upon public charity should be at once removed to a de- 
tention institution, and should remain there as long as may be neces- 
sary. The sufferer is infinitely better cared for in such an institution 
and his family are in a more favorable position to care for their own 
wants. Little opposition will be offered by the general public to the 
detention of these pauper cases. These sufferers almost invariably pass 



AND PREVENTION OF TUBERCULOSIS 335 

into our charitable institutions and remain there during life. With these 
cases the important question is detention. At present their residence 
in hospital and poorhouse is purely a matter of choice with the patient. 
The health authorities have no power to retain even a pauper case if 
the patient or his family chooses to object. For the safety of the public 
and the well-being of the families of these pauper cases the right to 
detain in hospital should be vested in the health authorities of every 
community, and the detention should be invariably enforced. This 
would entail no hardship upon the patient or his family. 

The detention of those who are able and willing to work is a very 
different matter. The public will have to be educated up to a com- 
prehension of the real danger of such cases before they will submit 
quietly to their detention. The danger to the public from these working 
consumptives cannot be doubted. Allow me to relate a typical case to 
which I was called while I was writing this paper, and which seemed 
forced upon me as a valuable illustration of my contention that it may 
be necessary to confine certain cases that are able to work. 

The patient was a young woman, who had just entered the family 
of one of my patients as a cook. In this family there was every reason 
for extreme caution on account of family history. The cook's severe 
cough attracted attention, and my opinion was immediately called for. 
I found a well marked case of tuberculosis. The patient stated that she 
had no home and no friends to whom she could go. She further stated 
that she had just come from a family of five for whom she had been 
doing all the work for the past winter. During that time she had had 
her " cold " and had consulted several physicians, who had given her 
cough mixtures. No effort had been made to confirm the diagnosis 
and no instruction given so far as I could learn. I had no power to 
control this case, and could only see that she left the employment of 
my patients. I have no question as to her being immediately employed 
in some other house, where possibly there will be less care shown and 
where she may remain for months. If I had had the power to report the 
case to some authorized official who could have committed her to a 
detention institution where she would have been given her only chance 
for recovery, it would have been an act of kindness to her and a 
measure of incalculable importance to the general public. Such cases 
can be reported almost without limit, and they are the most dangerous 
we have to contend with. 

Every effort to stay the spread of tuberculosis must be disappoint- 



336 NATIONAL ASSOCIATION FOR THE STUDY 

ing until the power is given to the proper authorities to detain this class 
of patients in suitable quarters where they can be treated and at the 
same time prevented from spreading infection broadcast. 

What should be the character of the institutions in which these 
unfortunates are to be cared for? In the endeavor to determine the 
most efficient method of caring for them, every effort should be made 
to avoid complicated and unnecessary measures that are liable to con- 
flict with each other and result in extravagance. When the public are 
just arriving at a proper comprehension of the necessity for action and 
even unavoidable expenditures seem excessive, it becomes the duty of 
all who have undertaken this work to aim at simplicity and economy 
of administration. To attempt to multiply institutions is to incur the 
risk of prejudicing the public against the whole movement. As a fact, 
there is no necessity for the construction of special detention institutions 
for the class of cases to which I have alluded. The rational and proper 
place for their detention is in properly equipped wards in our poor- 
houses. Every town of sufficient size has some place for the care of 
the indigent sick. In our larger cities these charitable institutions are 
developed upon a large scale, and already many are provided with 
separate wards and tents for the accommodation of tuberculous patients. 
Here they should be kept and judiciously cared for. I am well aware 
that there are very many poor-houses in our country that are scandal- 
ous, many in which the medical care is simply a farce, but that is no 
argument against my proposition. Public sentiment directed by such 
an organization as we represent here today will soon terminate such 
scandals and enforce upon the officers in charge suitable care for the 
unfortunate inmates. 

These cases, if they are to be subjected to detention, must come as 
a charge upon the State or upon the community in which they live. 
The vast number of cases renders the construction of state hospitals 
for their care practically impossible. State institutions for the care of 
incipient cases and cases that show reasonable expectation of per- 
manent improvement are really all that the public can expect. Into 
such institutions hopeful cases could be transferred from the town 
farms, and from these state institutions hopeless cases could be returned 
to the care of their own towns. The institution of tuberculosis wards 
in all communities will be in this way of vast benefit to the state in- 
stitutions that are being so widely developed at the present time. 

From an economic point of view there can be no question as to 



AND PREVENTION OF TUBERCULOSIS 337 

this plan for the care of indigent consumptives. The actual cost of 
preparing suitable wards upon our town farms for the reception of 
such cases would be nominal. The maintenance of the patient is al- 
ready met by the public. 

From a humanitarian point of view the town-farm system is by 
far superior to any other. If the patients have friends who care for 
them they are within reach, and they are free from the sense of iso- 
lation that must be associated with enforced residence in some remote 
and overcrowded state institution. Many of these sufferers are simply 
unfortunates, and if they prove tractable and worthy of confidence may 
be allowed to go about with a reasonable amount of freedom. 

I have endeavored to show that detention institutions for the care 
of pauper consumptives can be provided at small cost, and that resi- 
dence in such institutions should be required of such patients whenever 
it may be deemed advisable by the health authorities. As to the in- 
stitutions for the care of vicious consumptives, I may say that such 
institutions also are available with but slight expense. I can see no 
reason why the common jail is not all that is required. The term vi- 
cious can only be properly applied to such patients as intentionally 
defy the rules that have been established for their control. In most 
communities I prefer to believe that the number of such patients is 
very limited. Where they are found they class themselves willingly 
with other violators of the law and should receive no more consider- 
ation than other criminals. In many of the prisons in this country 
isolation rooms for tuberculous subjects are already provided. In such 
rooms the vicious consumptive should be required to work, and also 
required to keep the room clean as other inmates of jails are required 
to do. Such treatment would soon become unpopular, and viciously 
inclined consumptives would find compliance with the law more at- 
tractive. 

I arrived in one of our large cities some time since somewhere 
about midnight. I found the great union station empty. There were 
not over a dozen people in the whole immense room. Two facts were 
very impressively enforced upon my attention. First, everywhere I 
looked I read, $ioo fine for expectorating upon this floor. Second, 
under the brillant electric light the whole floor literally sparkled with 
expectoration. Either take such notices down and let the public ex- 
pectorate, or arrest a few offenders and let them appreciate the fact 
that there is a law that cannot be violated with impunity. A rigorous 



338 NAT. ASS'N for study AND PREV. OF TUBERCULOSIS 

enforcement of the laws necessary to control the action of consumptives 
would soon reduce the number of those viciously inclined to a minimum. 
The important factor in dealing with tuberculosis among indigent 
and unfortunate classes is the detention of and enforced treatment of 
all cases that are so placed as to constitute a danger to the community. 
Special institutions for the care of such cases are not required. 



WHAT CASES ARE SUITABLE FOR ADMISSION TO 
A STATE SANATORIUM FOR TUBERCULOSIS, 
ESPECIALLY IN NEW ENGLAND? 

By Herbert C. Clapp, A. M., M. D. 
Boston 



Very little has been written on this subject, and yet it is extremely 
desirable that a State's practicing physicians, on whom a State sana- 
torium must depend for its supply of patients, and who often make in- 
quiries, should know exactly as possible just what kinds of cases are 
acceptable. 

The present paper is an attempt to furnish the desired information, 
and is based on a practical experience of six and one-half years in the 
oldest State sanatorium in America, that in Rutland, Massachusetts. 

The successes in sanatorium treatment in properly selected cases 
are often so remarkable, and indeed almost miraculous, when measured 
by the therapeutic standards of a few years ago, that many physicians 
who are not well acquainted with the limitations of the subject, but who 
have heard exaggerated stories about sanatorium recoveries, and who 
have on this account become over-enthusiastic, often flatter us by think- 
ing that we can do impossibilities, and send to us for admission cases 
which are absolutely hopeless, expecting them to get well. 

These exaggerations and this excess of enthusiasm, instead of 
helping the cause, are sure to result in a reaction and in great injury 
to the legitimate claims for sanatorium treatment, which would be a 
calamity indeed. 

About equally injurious to the public welfare is the attitude of 
some other physicians (fortunately each year growing less in numbers), 
of skepticism as to the real efficacy of these modern methods, arising 
from a lack of knowledge on the subject and from an unwillingness to 
investigate. 

What physicians of the largest experience in lung diseases through- 

339 



340 NATIONAL ASSOCIATION FOR THE STUDY 

out the whole civilized world are now pretty well agreed upon, making 
slight allowances for the differences in climate, can be expressed some- 
what axiomatically as follows: Early cases (at least three-quarters 
of them) can be cured. Far advanced cases (with a few rare ex- 
ceptions) never can he cured. Moderately advanced and advanced 
cases can sometimes he cured, hut oftener not. They are always very 
doubtful. 

The word " cure " is often loosely used and thus gives rise to 
wrong impressions. Therefore it may be desirable to add that, at the 
date of discharge, some of us modestly call a satisfactory case not cured, 
but apparently cured or arrested. If, after a proper lapse of time, 
however, the patient continues well, the word " apparently " is dropped. 
But if the patient backslides, we think that the " cure " was more 
apparent than real, or else that a fresh infection has taken place. 

The rules for the admission of patients into sanatoria in general 
in this and other countries differ widely as to the stage of the disease. 
Private sanatoria with high charges naturally open their doors more 
widely than charitable sanatoria with low prices or with no fees, and 
the latter will have a larger number of applicants and can establish a 
higher standard for admission. With State institutions, as a rule, the 
standard should be higher still, and if so, their efficiency will thereby 
be increased. 

In conducting a State institution for the benefit of the citizens 
of the State, it is obviously the best and wisest policy to try to do the 
greatest good to the greatest number of people. This supreme object 
should be kept constantly in mind. In this instance it will be far better 
for the community at large, if we make incipient cases as nearly as pos- 
sible the standard for admission, because of their greater curability. 
There will always be a rush of advanced cases, while at first the supply 
of incipient applicants will not be sufficient to fill the beds. 

As the public becomes more and more educated, however, to the 
importance, nay, the necessity, for early treatment (and we should all 
do our best to further this education) the number of early applicants 
will increase. Until then the sensible method of procedure seems to 
be to select from all who apply those who seem most likely to receive 
permanent benefit, and that, too, in the shortest period of time, for ob- 
vious reasons of economy. If, for instance, we admit four cases that 
seem likely to be arrested or apparently cured in six months each, it 
costs no more and is manifestly a wiser expenditure of the State's 



AND PREVENTION OF TUBERCULOSIS 34I 

money than instead to admit one case that seems likely to get well in 
twenty-four months or two years ; and, besides, we can feel much more 
confident that the four will recover than the one. 

As the number of applications will vary from time to time, our 
minimum standard will necessarily vary within certain limits. If on a 
certain day we have five beds to fill and twenty-five applicants to 
choose from, we can naturally be more strict, other things being equal, 
than if only ten should apply. Our standard, therefore, must always 
be more or less flexible, unless we are content to have frequently a 
large number of vacant beds, which seems wasteful of money and of 
opportunity. 

In a public school all students who reach a certain standard are 
allowed to graduate, but only certain ones receive the prizes, which are 
provided in definite numbers. The examiners for a public sanatorium, 
in filling its beds are virtually giving out prizes, instead of invariably 
passing all who come up to a certain standard and of invariably reject- 
ing all others, which would make the whole question very much easier. 
Simple as this principle seems to be when stated as above and when 
studied in the abstract, it is exceedingly hard to explain satisfactorily 
to some physicians why at one time we feel obliged to refuse cases 
which may seem to be no worse than those which we may have accepted 
from them at another time, when we happened to have more vacancies. 
It is the old question of putting four quarts into a gallon jug. 

This principle of prize-giving ought to have the effect of stimu- 
lating early application. If it were made too easy to enter a State sana- 
torium and there were always plenty of room to be had for the asking 
at any time, the natural and common procrastination of the patient 
would be favored, and often with fatal results. 

So far in Massachusetts our rejection of undesirable patients has 
not constituted a great injustice to anybody. For while we never have 
claimed that those whom we reject are thereby considered by us as 
necessarily incurable (as is sometimes reported) — in fact, we de- 
cidedly disclaim such a statement — yet practically, so far as we can 
learn on inquiry, the great majority of those heard from whom we 
have rejected have failed to get well, although some of them under 
proper treatment have temporarily improved, and now and then possibly 
(but very rarely, we believe) one may have recovered. If we should 
accept these cases, as we are constantly begged to do, we should turn 
our curative institution into an old-fashioned home for incurables. 



342! NATIONAL ASSOCIATION FOR THE STUDY 

who, like the dog in the manger, would neither get well themselves 
nor by their preoccupation of the beds would they allow anybody else 
to get well. 

If, on the other hand, we had rejected as large a number of incip- 
ient cases, an injustice would have been done; for perhaps three- 
quarters of them might have been apparently cured if they had had a 
chance. When the number of incipient applicants increases so as to be 
as great as or greater than the number of our beds, it will certainly be 
the duty of the State to enlarge our accommodations. They have 
already been twice enlarged. Starting in 1898 with one hundred and 
seventy-five beds, the number was later increased to two hundred and 
sixty, and recently to three hundred and twenty-five, and soon prospec- 
tively it will be increased to four hundred. If there had been no 
enlargement from the beginning, our beds would now probably be about 
filled with incipient cases. 

What Cases to Exclude Positively 

There are some cases which must be refused admission to a State 
sanatorium at all hazards; and the examiner will very likely prefer, 
by the weeding-out process applied to these at the outset, to narrow 
down his range of vision preparatory to deciding the nicer points in- 
volved in selecting the best cases and at the same time in keeping the 
beds all full. 

It must not be understood that the cases now to be mentioned are 
invariably and inevitably incurable, but their average is low and they 
are not suitable for a good sanatorium. 

No bedridden patients should be accepted, nor even those who are 
confined to their rooms. If an applicant is not strong enough to ride 
some distance to the examining office, it is cause enough for his re- 
jection, for a time, at least. It is to be taken for granted that the 
patients in a first-class sanatorium are able to be up and about and to 
go to the dining-room for their meals, even if at other times their 
exercise has to be more or less restricted. If while in the sanatorium 
they get sick, of course they are put to bed and properly cared for ; but 
no persons should be deliberately received from the outside as bed- 
patients. 

No case of acute tuberculosis should be admitted, nor any case 
with high fever, nor even with a temperature which, after rest in bed 



AND PREVENTION OF TUBERCULOSIS 343 

with open windows for one or two weeks, does not come down to per- 
haps 100° or so in the afternoon. No case of tuberculous laryngeal 
complication, unless the trouble in the larynx as well as in the lungs 
is small. If the rules are very strict, all with tuberculous laryngeal 
complications should be excluded. A great many really good cases of 
pulmonary tuberculosis have a slight catarrhal hoarseness or roughness 
of the voice much of the time ; but no patient with more hoarseness 
than this should be admitted without a laryngoscopic examination. No 
complication of chronic diarrhcea, glycosuria, Bright's disease, melan- 
cholia, tuberculous disease of the kidney, pharynx, peritoneum, bones 
or joints should be allowed to enter. The last two are appropriate 
for a children's seaside sanatorium, but not for one for lung diseases. 
Not to be desired are cases of tuberculous deposit widely extended 
through one or both lungs, or through a large part of a lobe, (especially 
with the coarse bubbling rales of breaking-down lung tissue) ; no cases 
with clinical signs of cavities, no confirmed neurotics, no cases of ob- 
stinate dyspepsia and mal-assimilation. This latter disqualification per- 
haps needs explanation. The great majority of our acceptable 
applicants before entrance admit, on being questioned, that they have 
more or less lack of appetite, and flatulence, or sour stomach or other 
symptoms of indigestion ; but after a few weeks and occasionally even 
after a few days in the sanatorium we find most of them eating enor- 
mously and digesting well, and gaining many pounds in weight. The 
vital f)oint is this : proper nutrition is a sine qua non in our treatment. 
Without it we can do nothing. If the indigestion is too bad to be likely 
to allow of much improvement, the patient is inadmissible. Likewise 
if he has decided dyspnoea without exertion, marked insomnia, or a 
chronic very rapid pulse, even without fever. 

The serious symptoms and conditions above enumerated should 
always make us cautious about accepting such a patient, even if the 
physical signs of disease in his chest are small and indefinite. And yet, 
because small and indefinite, they have often induced physicians to 
send us as incipient cases those which were really almost hopeless. 
Whether we explain the fact by excessive virulence of the tubercle 
bacilli, or by a remarkable receptivity and fertility of the soil in the 
patient, true it is that in some persons it takes only a little of the tuber- 
culous poison to produce a tremendous infection of the whole system ; 
while in other persons a large solid mass, evidenced by tubular breath- 
ing, bronchophony and even flatness on percussion, may sometimes 



344 NATIONAL ASSOCIATION FOR THE STUDY 

remain latent and almost innocuous for months, if not for years, in the 
upper part of a lung. 

Very decided complications of bronchitis, asthma and emphysema 
constitute another class of cases which our experience has amply dem- 
onstrated it is not wise to accept at a sanatorium in a climate as cold and 
as variable as that in New England. They cannot bear such exposure 
as is necessary for almost all of our tuberculous patients and should, 
if possible, seek a warmer climate, although for most cases of tuber- 
culosis without these complications our New England climate has been 
proved to do its best work in the coldest part of the year, contrary to 
popular ideas. 

Two other classes of cases are likely to be excluded from our sana- 
torium on account of practical difficulties met with in our experience 
— children under fourteen years of age and adults over fifty, although 
we are not bound by a hard and fast rule. Not that children are in- 
curable, but they can.be better treated in institutions by themselves; 
and many people (not all) over 50 or 60 yrs. old, of the classes that 
come to us, have not vigor enough to stand the winter exposure which 
we deem absolutely necessary for younger people. 

We follow pretty closely the rule, which seems to us wise, to make 
one year the maximiun duration of residence of patients ; not because 
we despair of their recovery later, if they are not well then, but because 
by that time they have had their share and we need the beds for others, 
and also because a year's training in good living ought to enable them 
to carry on the good work alone outside. 

Acceptable Cases 

A sanatorium cannot get its cases too early for the best and quick- 
est results. If tubercle bacilli are found in the sputum, no matter how 
strong the patient is, no matter how well he looks and feels, he will 
make no mistake in applying for admission at once. Nor should his 
physician feel obliged to wait for tubercle bacilli to appear in his spu- 
tum. One who is skilled in auscultation and percussion can (not always 
but very often) detect the disease by this most important means, in 
addition to a careful investigation of the symptoms and personal and 
family history of the patient, many weeks before the bacilli appear in 
the sputum or even before the sputum itself appears, and thus save 
valuable time which may in some cases make the difference between 



AND PREVENTION OF TUBERCULOSIS 345 

the life and death of the patient.'^ Afebrile cases are the most desirable. 
In cases which do not have enough fever to bar acceptance, our first 
effort is to reduce the temperature to normal. 

Other things being equal, the smaller the size of the tubercular 
deposit or deposits, the more favorable the case. If at one apex, it is 
better than in both. We use the word incipient rather loosely. One 
case may progress as far in two months as another in five years, and 
we call them both incipient, and they may both get well. Time is not 
necessarily an important element in the definition. Yet, if possible, 
we like to get cases within one or two or three months from their first 
symptoms, such as cough, haemoptysis, etc. The less severe the consti- 
tutional symptoms the better. 

We should, if possible, be convinced from the personal and family 
history of the applicant that he has sufficient underlying vitality (a 
" tough streak ") to enable him under favorable surroundings to re- 
sist successfully the invasion of the disease. 

I think the importance of character in influencing recovery is 
greatly underestimated. A man with a strong will, able to control his 
passions, and to regulate his habits carefully, and obediently to live the 
proper life (to " take the treatment " as we call it) whether he is 
watched or not, will stand a much better chance of recovery, especially 
if he has a cheerful disposition and a good stomach, than a weak and 
irresolute character, or than one bound hand and foot by the bonds of 
dissipation. Even if by keeping him strictly under our thumbs while 
in the sanatorium we send such weak or dissipated man out as " ap- 
parently cured," what is there to prevent his backsliding later? Are 
not his reception and treatment often a waste of the State's money ? 

Theoretically a certain amount of intelligence should be demanded 
of a patient to enable him to live aright after, he has left us, in order to 
keep well. Practically we have been surprised to find out by our re- 
sults how comparatively little of this is absolutely necessary, provided 
the right moral stamina is present, because of the thorough practical 
drill in right living while with us, extending over a number of months, 
here a little and there a little. 

Contrary to a widespread popular belief, haemoptysis is not gener- 
ally an unfavorable symptom in the prognosis of early cases, unless it 
is very large and frequent. Practically we accept most cases with 

'"The Dangers oi the Microscope in the Early Diagnosis of Pulmonary 
Tuberculosis," H. C. Clapp, Amcr. Med., Dec. lo, 1904- 



34^ NATIONAL ASSOCIATION FOR THE STUDY 

hemorrhages as quickly as those without. In the early diagnosis it is 
very valuable to us, being pathognomic of tuberculosis in the great ma- 
jority of cases, in the absence of organic heart-disease. It is also very 
valuable to the patient, being to him a good danger-signal, warning him 
to seek relief at once. 

In later cases, which we are apt to refuse for other reasons, 
haemoptysis is often followed by unfavorable complications. 

After reading the above restrictions and limitations advisable in 
the admission of patients, some physicians may think that we want only 
well persons to treat at the sanatorium. Indeed, this criticism has 
really been made. The fact is (although we regret to say it) that at 
the present time a large number of our physicians, even among those in 
good repute, are often only able to recognize a case of tuberculosis after 
it has reached the incurable or doubtful stage. Soon, however, we 
hope that this will be changed, and that they will be well posted on the 
early diagnosis of the disease, about which so much has been written of 
late. When most of the early cases are cured, there will be few left to 
become incurable. 

No examiner is infallible. Occasionally a case which he thinks 
ought to do well suddenly develops an unfavorable complication and 
goes from bad to worse. Occasionally a bad case surprises him by im- 
proving remarkably. Undoubtedly a part of his difficulty consists in 
his inability to measure the varying amounts of the mysterious power of 
resistance in the patient. Still, in most cases, after proper training and 
experience, he can judge with a considerable degree of accuracy. This 
judgment would be increased in value if in some of the more doubtful 
cases a short period of close and constant observation or " probation " 
could be established, either in the patient's home, or in a near-by hospi- 
tal or in a boarding-place in the town where the sanatorium is situated, 
or even in the sanatorium itself. We often now admit patients for a 
limited time on trial, and discharge them if on the one hand with con- 
siderable disease they do not respond to the treatment as well as we 
think they ought to do, or, on the other hand, if we decide after close 
watching that they have no tuberculosis at all. 

Illustrative Cases 
The following three cases are appended in abstract, as samples of 
the kind we like to admit and illustrative of different phases of the 
disease. 



AND PREVENTION OF TUBERCULOSIS 347 

The first is presented as an ideal incipient case, and might serve as 
a model. If most of our cases were like it, our institution would be an 
ideal sanatorium. Not only would our records be ideal, but also 
(which is the same thing) our results, as shown in increased benefit to 
the community. It may not be out of place to add that this patient was 
in every respect a model young man. 

Case No. 8i6. — W. F. A., 28 years old. A physician, with a previous 
college education (A. B.). Entered Feb. 15, igoi. Had coughed 2j^ months. 
Haemoptysis one ounce and a half on Jan. 5. SHghtly hoarse at times. Tem- 
perature 98.6°, pulse 80. Anaemic. Slight loss of weight from his normal of 
119 lbs. 5 feet 85^ inches tall. His physical signs were dullness, broncho-vesic- 
ular respiration, bronchophony at the right apex extending down to the second 
rib, with a very slight depression above and below the clavicle. His sputum, 
which had not been examined before entrance, showed tubercle bacilli immediate- 
ly thereafter. By April 29, his physical signs had diminished in amount and he 
had gained 14 lbs. and had lost his cough. He left June 29 after a stay of 4^ 
months, and has remained well since, now almost 4 years, in the active practice 
of medicine. 

The next case we classed as incipient, for want of a better name, 
because, although the symptoms dated back three or four years, yet the 
resistance of the system had been such that the amount of the deposit 
was small, as well as the constitutional disturbance. Still, 5 months to 
obtain arrest in such a case is exceptionally short. 

Case No. 1372. — C. A., age 27 years, waitress. Entered May 28, 1902. 
Sent by Dr. E. O. Otis. Cough 3 or 4 years, dyspnoea on exertion, dyspepsia, 
poor sleep, weak and tired, temperature 99.2°, pulse 84, lost 3 lbs. from her 
normal of 120 lbs.; s feet 4; tubercle bacilli in sputum, nasal catarrh, slight 
deposit at right apex to second rib. Discharged Oct. 29 apparently cured and 
19 lbs. heavier than at entrance. Has remained well since. 

The next case was seen very early, had apparently about as much 
trouble, and yet took twice as long (10 months) to be arrested. We 
wish that physicians who send patients would not promise them a cure 
in three months, as some do. 

Case No. 1412. — Entered June 26, 1902. N. A., Boston, 23 years, domestic. 
Father died of phthisis. Cough i month, haemoptysis June 16, 3 ounces, and 
June 20 one ounce; slightly hoarse, appetite fair, indigestion, dyspnoea on exer- 
tion, very pale, tired, scanty menstruation, lost weight ; 5 feet 6 ; afebrile, tubercle 
bacilli in sputum. The bacilli continued until December. Discharged April 22, 
1903, apparently cured, having gained 23 lbs. 

The next case is not quoted as a model for admission, but illus- 
trates to a remarkable degree the possibilities of sanatorium treatment 
where there has been pulmonary hemorrhage. As a symptom by itself 
in early cases we very seldom consider it a bar to admission. 



348 NAT. ASS'N for study AND PREV. OF TUBERCULOSIS 

Case No. 1261. — J. F. R., Boston, 32 years, letter-carrier. Admitted Feb- 
ruary 12, 1902. Has coughed four years, and has had two children die of tuber- 
cular meningitis. Has tubercle bacilli in sputum. Has had by actual count 
ninety-one hemorrhages from the lungs in 3^ years, averaging about a half a 
cupful each. Other prominent symptoms were dyspnoea on exertion, anaemia, 
constipation, lassitude and loss of weight. Considerable deposit at right apex 
to 3rd or 4th rib ; less at left apex to 2nd rib. 

He gained in every way during his stay of about a year, and in that time 
lost only about 6 ounces of blood, and that on three days in one week. Weight 
increased about 30 lbs. When he left (his year being up) although we did not 
record him as cured, yet his condition has improved to such an extent that he 
has ever since been strong and has been able to do his full work as letter-carrier 
in an out-of-town district, not losing a single day from sickness during the last 
two years. 

We wish that more physicians would visit our sanatorium and see 
for themselves a Httle of the good work which is being done there. 



SIX YEARS' EXPERIENCE AT THE MASSACHUSETTS 
STATE SANATORIUM FOR TUBERCULOSIS AT 
RUTLAND, MASS. 

By Vincent Y. Bowditch, M. D., and Henry B, Dunham, M. D. 
Boston Rutland 



In presenting the results of six years' experience in the treatment 
of tuberculosis chiefly in the pulmonary form at the State Sanatorium in 
Rutland, Mass., it is with pleasure and pride that we recall the fact that 
Massachusetts was the first state in the Union to adopt as a public en- 
terprise methods which had been successfully used for many years 
abroad and later in our own country at private institutions, notably that 
of Dr. Trudeau at Saranac Lake, New York. 

It should be remembered, moreover, that the idea of treating this 
disease with any hope of success in a large number of cases in a moist, 
harsh climate like that of New England had been regarded with ex- 
treme doubt, to say the least, among the rank and file of the medical 
profession. The results obtained in previous years, however, at the 
small charitable institution, viz: the Sharon sanatorium at Sharon, 
Mass., situated only twelve miles from the ocean and at about 250 feet 
only above sea level, had attracted the attention of the earlier Board of 
Trustees of the State Sanatorium and had encouraged them, as stated 
in one of their early reports, to make the institution at Rutland a sana- 
torium (in the strict sense of the word) for the earlier cases of disease 
and not a mere hospital for the hopelessly ill. 

The state owes a debt of gratitude for this decision to the foresight 
and determination of the Board of Trustees, both past and present, and 
notably to Dr. Alfred Worcester, of Waltham, Mass., now no longer a 
member of the Board. To his enthusiasm and persistency is doubtless 
due much of whatever success the sanatorium has attained as a place 
where people can go with the hope of arresting a disease which is 
threatening life. 

349 



350 NATIONAL ASSOCIATION FOR THE STUDY 

The Legislature has in times past been generous in its appropria- 
tions, far more so than in some other states where earnest endeavors are 
being made by public-spirited men to follow the example of Massachu- 
setts. In this respect we have little cause to complain. The difficulties 
which have stood in the way of those in charge of the institution have, 
however, been many. The fact that it was a state corporation made it of 
the nature of a new and great experiment, offering the vicissitudes with 
which great experiments are always obliged to grapple. Naturally from 
time to time the methods have been subjected to severe criticism, often 
doubtless with best intent, from those who we have reason to believe 
have sometimes not fully understood the precise nature, the necessities, 
and the difficulties of management of such an institution. While not 
wishing to claim immunity from liability to make mistakes, and while 
desiring to listen to kindly criticism, we nevertheless feel that had we 
not endeavored to adhere as closely as possible to the expressed wish of 
the Trustees that only hopeful cases should be admitted and that pro- 
vision should be made elsewhere for the hopelessly sick, we should have 
been unable to accomplish results which have attracted the attention of 
the public both at home and abroad, results which have encouraged 
other states to erect similar institutions elsewhere in the Union. 

It should be distinctly understood, however, that while we have en- 
deavored to adhere to this standard, feeling that in this way we were 
doing " the greatest good to the greatest number," and while our fail- 
ure to accept many advanced cases has been the frequent cause of ad- 
verse criticism not only from the laity, but I regret to say, from our 
own profession, yet, as a matter of fact, the majority of patients ad- 
mitted have been far past the incipient stage of disease, many of them 
having such advanced signs that there has been little hope of accom- 
plishing anything more than a temporary amelioration of the symptoms. 
With these cases, however, there has at times been a most gratifying 
and unexpected improvement, and when we consider the means that we 
have at our disposal, the insufficient number of assistants necessary for 
the proper supervision of large numbers of patients, and the kind of 
cases dealt with, we have reason to be pleased at the favorable results 
thus far accomplished. We plead at the same time for increased facili- 
ties in our work and set our faces strongly against increasing the size 
of any such institution lest it become elephantine in dimensions, pro- 
portionately difficulL to manage, and therefore less productive of favor- 
able results. 



AND PREVENTION OF TUBERCULOSIS 35 1 

To illustrate our meaning it will be well to state that at the outset, 
in the original bill before the Legislature, provision was to have been 
made for two hundred patients. Owing to lack of funds, only one hun- 
dred and seventy-five could be received in the earlier months. Later, 
following an additional appropriation and for administrative reasons, 
accommodations were made for two hundred and fifty patients. For 
the care of these patients, most of them ambulant and able to take active 
exercise, we were obliged to work with but one assistant for each of the 
two medical departments of the sanatorium. Up to the time of the ap- 
pointment of an assistant whose duties were practically confined to the 
examination of the sputa and urine, such work was chiefly done in the 
laboratories of the medical schools of the Harvard and Boston Uni- 
versities, institutions to which we owe a debt of gratitude for helping 
us over a very awkward and difficult stage in our progress. 

Later we again had to face the determination of our state legisla- 
ture to enlarge the institution by the addition of new buildings to bring 
our capacity up to nearly four hundred beds, a plan which we believed 
to be fraught with danger to the accomplishment of best results, for the 
reasons before mentioned. With the recent appointment of another 
assistant physician, we are now striving to hold to the standard origi- 
nally set, although we have had to meet the fact that in order to keep the 
beds filled an unusually large number of well-advanced cases have been 
admitted. The number of assistant physicians and nurses, moreover, is 
still insufficient to exert the supervision necessary for the best results. 

These introductory statements are made without the least desire 
to criticise those who, while doing their utmost in the fight against tu- 
berculosis, may differ with us in the details of the work. We wish 
only to emphasize the aims and requirements of the institution, and the 
difficulties which have had to be met in order that others may profit by 
our mistakes as well as by whatever success we may have attained. 

Since the opening of the sanatorium in October, 1898, up to May 
I, 1905, 3,300 have been admitted, and there have been approximately 
7,000 applicants. 

The results of treatment are recorded in the following tables of 
percentages taken from the Eighth Annual Report, Sept. 30, 1904. 

In recording results a few words of explanation are necessary. It 
has been the policy of our own department up to the present to use 
merely the term " arrested " in those cases in which all outward symp- 
toms have ceased, such as cough, sputa containing bacilli, fever, etc., the 



352 NATIONAL ASSOCIATION FOR THE STUDY 

general condition being one apparently of perfect health at time of dis- 
charge. The terms " cured " and even " apparently cured " have, up to 
the present, not been used by our department, although the condition 
of many of the patients would often seem to justify these expressions. 
As used by us thus far, the term " arrested " is equivalent to the less 
conservative one, " apparently cured " employed by our colleagues in 
the other department of the sanatorium. In deference to the wishes of 
the Trustees, therefore, in the following quotation from the last Annual 
Report the results of the two departments are classed together. 



Tables Showing Results of Treatment 

From Eighth Annual Report 

Comparison of Percentages During the First Six Years, up to October i, 1904. 

Year of Discharge 1899 1900 1901 1902 1903 1904 

Percent, of " arrested " and " apparently cured " 

cases 

Percent, of all classes of " improved " cases . 
Percent, of "not improved" cases 26 

Percentage of Incipient Cases which were " Arrested " and " Apparently Cured." 

Year 1899 1900 1901 1902 1903 1904 

Percent 65 73 73 72 73 76 

In comparing the results obtained in the last year with those of 
former years, we may notice the significant fact that the percentage of 
incipient cases which have been discharged as " arrested " or " appar- 
ently cured " has steadily increased, a proof of the importance of send- 
ing cases early in the history of disease, instead of waiting until the 
symptoms become more marked. 

It will be noticed that the percentage of " arrested " or " apparently 
cured " of the total number of cases was somewhat less last year than 
the preceding year, which, at first sight, would seem to be discouraging. 
When we study the facts, however, we find reason to be encouraged. 
The acts of the Legislature have twice increased the capacity of the 
sanatorium. In order to fill the 260 beds available during the last year, 
a larger proportion of advanced cases was admitted than before. The 
average length of stay, moreover, was for several reasons lessened 
during the last year, with a consequent increase in the number of 
patients admitted. Both of these facts naturally tended to diminish the 



34 


42 


46 


48 


49 


45 


40 


45 


48 


45 


43 


48 


26 


13 


6 


7 


8 


7 



AND PREVENTION OF TUBERCULOSIS 353 

relative number of cases discharged as " arrested " or " apparently 
cured," although the actual number of such cases was larger than be- 
fore (258). Taking these facts into consideration, therefore, we feel 
that there is every reason for encouragement, and that by properly 
meeting new conditions we can increase the amount of good done to 
the community by the sanatorium. 



Subsequent Histories of " Arrested Cases " in Our Department 
OF the Sanatorium up to May i, 1905 

The subsequent histories of patients who have been at the sanato- 
rium are naturally of great interest. The following tables have been 
made after painstaking endeavors to trace all those who left the insti- 
tution with the disease " arrested," in our own department, which 
represents a majority of the whole number of patients in the sanato- 
rium. It is still somewhat early to make very definite conclusions as to 
the lasting effects of the treatment, when we consider the nature of the 
disease ; but even at this stage in the history of the sanatorium enough 
can be evolved to be of value. It must be remembered that we are 
dealing with people of very limited means, often with the poorest 
classes, who naturally return as a rule to less favorable conditions of 
living than the well-to-do. Favorable results in such cases are therefore 
all the more gratifying. 

Although earnest endeavors are made to place people in hygienic 
surroundings after they leave the sanatorium, and to induce those who 
have lived in the city to take up a country life, yet as a matter of fact 
the great majority return from necessity even if not to exactly the same 
conditions, yet to employments which are morfe or less unfavorable tQ 
health. Sanatorium methods, moreover, are of course not as rigidly 
carried out after discharge ; but it is interesting and gratifying to note 
that the majority persist in keeping their windows open at night and 
dislike any lack of ventilation. All of these facts go to prove the educa- 
tional value of the institution, and augur well for the cause of preventive 
medicine even when our efforts to overcome the disease may not be 
successful in individual cases. 

In regard to those from whom no replies have been thus far re- 
ceived, it should be stated that it not infrequently happens that former 
patients for various reasons will not reply to repeated inquiries, and it 



354 NATIONAL ASSOCIATION FOR THE STUDY 

has been oftentimes casually discovered that they are in excellent 
health ; so that it would not be fair to state that the lack of response is 
equivalent to an unfavorable reply. 

From the tables it will be seen that the number of those (35) who 
left our department over five years ago with the disease " arrested " 
and are now known to be in active work, amounts to probably 70%, 
when we take into consideration those who have not recently been 
heard from, but who, we have good reason to believe, are active wage- 
earners still. How far the return to unhygienic conditions has been the 
cause of relapse and how far death may have been due to other causes 
than tuberculosis it is of course impossible to say with certainty. Up to 
May I, 1905, of the whole number of " arrested " cases (539) dis- 
charged from our department alone up to Oct. i, 1904, 45 have died; 
but the cause of death in four of these by authentic report was either 
accident or intercurrent disease not of tubercular nature. This 
would make the number of deaths of which we have certain knowledge, 
therefore, among the " arrested " cases only about 8% thus far. 

The fact that a considerable number (63) of those who left 
" improved," with their symptoms still present to some degree, have 
since reached a condition of " arrest " is another gratifying evidence of 
what can be done at the sanatorium to instruct patients how to regain 
their health when left to their own devices under favorable conditions. 
It should be stated in this connection also that in this same period there 
were 647 cases discharged from our department in all grades of im- 
provement, but still having some symptoms. Among these have been 
reported 191 deaths ; but the reports thus far received from those who 
are living show that the majority are now working. 

It adds to the reliability of these statistics to know that hundreds 
of examinations have been ma.de by the medical staff of past patients, 
who are encouraged to return regularly for purposes of comparison and 
counsel. The Boston Association for the Relief and Control of Tuber- 
culosis has been very helpful to us in this work. 

In trying to determine how many patients after leaving the sana- 
torium have made a change of residence, of climate or occupation, it is 
most encouraging to note that although the majority of all patients dis- 
charged as " arrested " have been obliged for many reasons to disregard 
our advice and return to the same places of residences and occupation 
as before entrance, yet they are now hard at work and in good condi- 
tion. A very small percentage only have made a change of climate. 



AND PREVENTION OF TUBERCULOSIS 355 

This brings us to the much mooted question as to the advisability 
or necessity of change of climate, and it is perhaps well to reiterate 
statements which have been made before in other papers on the subject. 
We hold practically the same view which we have always had, viz., 
that while undoubtedly, ceteris paribus, a climate which presents the 
best opportunities for life in the open air with the maximum of sun- 
shine is the best for the consumptive, and that the chances of relapse 
there are smaller, yet for hundreds and thousands of those who for 
many reasons cannot go far away we have certain knowledge that a 
large percentage can regain and keep their health by comparatively sim- 
ple methods near home. We know also that while undoubtedly thou- 
sands of patients who have gone to distant health resorts have done 
well, there are some who have lost ground there and who upon return 
have again improved. In short we do not sympathize with what we 
deem the equally sweeping assertions of those who maintain that it is no 
longer necessary to send patients far away and those who insist on the 
other hand that an entire change of climate is the sine qua non of suc- 
cess. 

Subsequent History of Patients on Dr. Bowditch's Service 
UP TO May ist, 1905 

Year of discharge 1899 1900 1901 1902 1903 1904 Totals 

Number of patients discharged with 

the " disease arrested " . . 35 56 85 90 132 141 539 
Number of patients now in good 

health and working .... 18 39 60 65 105 113 400 
Number of patients who have not 

replied to letters lately ... 2 9 3 8 10 17 50 

Number of patients who cannot 

be traced 4 i 2 I i 9 

Number of patients in whom the 

symptoms have returned . . 2 2 9 8 4 11 36 

Died 9 5 II 8 12 45^ 

Patients who left the Sanatorium 

" improved," but who have 

now reached a condition of 

"arrest" 9 5 14 7 15 13 63 

Of those who died in the Class of 1899, all had returned to the same 
residences, except one, who went from Springfield to Boston, and one, who 
went from Boston to Colorado. 

All had returned to the same occupations, except one girl, who married 
and had a child. 

* Four have died from causes other than tuberculosis. 



35^ NATIONAL ASSOCIATION FOR THE STUDY 

Of the i8 at work now, all returned to the same residences, except two; 
one went from Boston to Colorado, and one from Worcester to a Canadian town. 

All returned to the same occupation, as before entrance. 

All but 2 of the nine "arrested since discharge" cases bettered their 
residences, 2 of them being in Colorado. 

In the Class of 1900, of the 7 patients who died or relapsed, 2 changed 
occupation or residence, and one changed climate. 

Of the 39 patients who remain well, 13 changed occupation or residence 
and 2 changed climate. 

In the Class of 1901, of those who relapsed (20), i changed climate and 
occupation; 2 died from causes other than tuberculosis. 
Of those who are in good condition (60), 

10 made a change of residence, 
3 made a change of climate, 

6 made a change of occupation. 

In the Class of 1902, of those who relapsed (16), 

1 changed climate, 

3 changed residence, 

2 changed occupation. 

Of those who are now in good health (65), 

3 changed climate, 
12 changed residence, 

7 changed occupation. 



Methods of Treatment 

It will be impossible in this paper to do more than give the general 
outline of methods of treatment at Rutland. For the most part we em- 
ploy what are recognized now as the essentials in all sanatoria for tuber- 
culous patients, viz., the greatest amount possible of fresh air, good 
food, judicious exercise and general supervision as far as is possible 
in order to guard against the mistakes which arise through ignorance 
in whatever direction. 

As to the use of any one specific remedy, we can frankly say that 
we have thus far found nothing to equal the effect of the so-called hy- 
gienic treatment although we have at times experimented with certain 
vaunted remedies with negative results. In the use of tuberculin we 
have held a conservative position, doubtless an unwarrantable one in 
the minds of some of its advocates. We can say, however, that in tak- 
ing this position it has been with no wish to shut our eyes obstinately 
to what shall be proved of undoubted efficacy, but because of honest 



AND PREVENTION OF TUBERCULOSIS 357 

doubt and in order to be better able to make comparisons after a reason- 
able experience with one method. Deeply impressed if not wholly con- 
vinced yet by the statements and experience of those for whose 
opinions we have great respect, we have in many cases used tuberculin 
for diagnostic purposes, with the result that while believing it to be not 
an infallible test and that error may arise, we nevertheless believe it has 
at times been of much value in determining the nature of doubtful cases, 
and that in the future, with the possibility of establishing a definite 
standard in the preparations, it can be of still greater service. 

Of its use therapeutically, about which so much is said and written 
pro and con, we can say that recently in a few cases which have for sev- 
eral months seemed to remain in statu quo under the usual hygienic 
methods, we have begun its use in accordance with the recommendations 
of its advocates. Our experience thus far, however, has been too 
meagre to warrant any positive opinion. We can certainly say that we 
have seen no harm come from its use, and in one or two cases the im- 
provement in symptoms has encouraged us to pursue our investigations 
still farther. 

One word in reference to exercise. One great difficulty in a large 
sanatorium like that at Rutland is to provide sufficient and healthful 
amusement to keep the patients content. With men especially, many of 
them in vigorous condition, chafing at confinement, we allow, in care- 
fully selected cases, a certain amount of freedom of exercise which on 
general principles some would think unwise. Believing that the moral 
effect of outdoor games will outweigh the possible deleterious effect of 
active exercise, we have allowed some of the patients who are approach- 
ing a state of arrest of disease to indulge at times in baseball and other 
games of a less active nature. It should be distinctly understood, how- 
ever, that these are the exceptions to the general rule. While an 
occasional mishap may have occurred, we believe that much less evil 
has come from this than would be naturally supposed at first thought. 
At the same time there is a marked beneficial effect upon the mental 
condition of the patients in allowing them this comparative freedom. 
Incidently it should be said that in properly selected cases we 
thoroughly believe in the good effect of moderate calisthenic exercises 
for the chest, and disagree wholly with those who make the (to us) 
sweeping assertion that every tubercular chest should be kept in as ab- 
solute a state of immobility as possible, no matter how slight the amount 
of disease. That rest of the diseased organs, as far as it is possible to 



358 NAT. ass'n for study and prev. of tuberculosis 

obtain it, is required for cases of every active trouble, we believe to be 
true ; but we also maintain from experience that expansion of the lungs 
at regular intervals, where the disease is quiescent, is productive of ex- 
cellent results. 

What, then, can we say of the wisdom of establishing a State sana- 
torium after these six years of experience at Rutland? Have the 
results justified the original outlay, and can we urge other States to do 
likewise ? In our opinion there can be but one answer to this question, 
and that in the strongest affirmative. No one who has studied the 
question of tuberculosis and who has carefully and conscientiously fol- 
lowed the working of methods for relief of the victims can fail to be 
struck forcibly by what has been already done at Rutland, first from the 
humanitarian point of view, and second from the utilitarian side of the 
question. As case after case comes before our eyes and we watch the 
gradual changes in aspect from one of disease and invalidism to that 
of health and vigor, and contrast present conditions with the wretched 
hopelessness of former years, can we, if we have a spark of human 
sympathy in our breasts, fail to rejoice that we now can hold out the 
hope of renewed health to many of those who otherwise from lack of 
means would be practically doomed to die a lingering death ? 

From the humanitarian point of view alone we feel that the Rut- 
land Sanatorium has given already sufficient justification of its exist- 
ence in spite of the inevitable discouragement and sense of failure 
which must come in a certain number of cases. When we consider the 
utilitarian side, can there be any doubt, when reading the large per- 
centage of those who have returned to their homes and have become 
active wage-earners again, that the money expended has been fully 
repaid in the renewed vigor and usefulness of large numbers of our 
citizens ? 

It has been, moreover, often said, but the truth cannot be empha- 
sized too much, that quite apart from the good done to the individual 
patient, stands the far-reaching educational effect of such institutions 
upon the community. This cannot be reckoned in figures, but that it is 
a great power for future good no rational person, if he has had even 
small experience, can deny. 

Thus we give the results of our personal experience. That the 
Massachusetts institution may be but the small beginning of a similar 
movement all over our country in the fight against tuberculosis is the 
earn'est wish of every one connected with the Rutland sanatorium. 



TENT COLONIES IN MANAGEMENT OF 
TUBERCULOSIS 

By J. W. Pettit, M. D. 
Ottawa, 111. 



The difficulties in carrying out the open-air treatment of tubercu- 
losis are so formidable that any method which will cheapen or simplify 
the treatment should be favorably considered. The cheapest, simplest 
and least expensive method, which will protect a patient from the in- 
clemency of the weather and supply him with the largest amount of the 
best possible air is the one which commends itself for scientific and 
economic reasons. A properly constructed tent fulfils these conditions 
more perfectly than any plan yet devised. 

The probable reason why the tent is not more in use is because of 
the popular misconception as to its discomforts. Its advantages in more 
equable climates are not questioned. It has been assumed that it is 
impracticable in so-called unfavorable climates, especially in zero 
weather. It was natural that sanatoria for the treatment of tuberculosis 
should at first copy the usual methods of hospital construction, hence 
there has risen a too expensive ideal. Fresh air is the cheapest thing in 
the world. Our aim should be to supply the maximum amount of pure 
air at a minimum expense. 

In favorable climates the tent has been 'largely and successfully 
used, but it did not occur to even its most sanguine supporters that it 
was practicable in unfavorable climates. It was more by accident than 
by design that it has been discovered that tent life is as applicable and 
even more efficient in cold than in warm climates. At first thought 
it seems incredible that patients can find comfort in an ordinary tent 
at a temperature of twenty-five degrees below zero. Yet this is just 
what the patients at the Ottawa Tent Colony have done during the 
past winter, one of the most severe we have experienced in the north- 
west for many years. 

Inasmuch as no systematic attempt had ever been made to treat 

359 



360 NATIONAL ASSOCIATION FOR THE STUDY 

tuberculosis in Illinois by modern methods, the State Medical Society- 
established a Tent Colony, to demonstrate that this disease can be as 
successfully treated there as elsewhere. The demonstration was only 
intended to cover a period of a few months ; hence it was desirable that 
the equipment be inexpensive. To this end the tent was adopted. It 
was not believed at the time that this method would be feasible in cold 
weather, or would be accepted by the patients even if it were ; therefore 
a large building was secured where they could be housed during the 
winter. A part of this building was arranged for a dining-room and 
kitchen and the tents pitched round about it, with the understanding 
that as the cold weather came on patients could move in at their 
pleasure. In order to keep them out as long as possible, each tent was 
supplied with an oil stove, which was expected to provide only suffi- 
cient warmth for chilly or moderately cold weather. It was anticipated 
that as it grew colder the patients should go indoors. But they did not : 
even the most delicate women remained in their tents. Instead of 
suffering from the cold, they were comfortable and rather enjoyed the 
experience. Several of those who were accustomed to living in frame 
houses declared they would have been less comfortable had they been 
at home. Even new arrivals, during the extremely cold weather, in- 
sisted upon going into tents. This was believed to be too severe a 
test, but in no instance had we cause to regret yielding to the entreaties 
of the patients. Their action is the more remarkable when we take into 
account that many, if not most of them, had come from homes where 
it was difficult to drive them away from the vitiated and superheated 
atmosphere of badly ventilated houses. 

Since it has been demonstrated that the tent is practicable in cold 
climates, it should be used more extensively. It fulfils the conditions 
most perfectly from a scientific standpoint. The method of construc- 
tion is not very important, as it is difficult to foul the air of a tent, 
even when no means of ventilation are provided. It is a very easy 
matter, however, to provide for ventilation and this should be done. 

From an economic standpoint the tent commends itself. The 
housing of tuberculous patients in buildings is not only unnecessary, 
but is in violation of an essential principle which has for its object 
providing the patient with fresh air. The method is as irrational as it 
is expensive. The only argument that can reasonably be adduced for 
placing patients in buildings is that it is necessary to keep them warm. 
It costs from four hundred to five hundred dollars to house a patient 



AND PREVENTION OF TUBERCULOSIS 36 1 

in an ordinary building according to the plan usually followed in hospi- 
tal construction. A tent with necessary furnishings need not cost more 
than one-tenth this sum. 

The difficulty in keeping patients in the open air is well known. 
Every temptation placed before them in the way of indoor comforts 
only adds to the difficulty. As well might we seat a hungry man at 
a table laden with good food and expect him not to eat as to place a 
tuberculous patient in a comfortable building and expect him to keep 
his doors and windows open. A few patients will do it ; more will not. 
The only way to insure patients getting fresh air is to place them where 
they can get nothing else. 

The privacy of the patient's sleeping apartments should be pre- 
served. This can be done in a tent without violating an essential prin- 
ciple of treatment, but cannot in a building without adding enormously 
to the expense. 

To be consistent, we must keep our patients out of doors, not part 
of the time, but all the time. In no other way can this be done so 
easily and satisfactorily as in a tent. It is generally conceded that a 
tent is an ideal method of housing tuberculous patients in a mild climate. 
Every argument which may be urged in favor of its use in a mild cli- 
mate applies with equal force to any section of the United States. 

Precedent, prejudice, misconception and ignorance must be over- 
come before the value of the tent in the treatment of tuberculosis will 
be recognized. No amount of argument will settle this question. A 
practical demonstration is all that is needed to convince the most 
skeptical. 

Any proposition looking to the care of the vast army of consump- 
tives resolves itself in its final analysis into a question of dollars and 
cents. It is not possible, except on the most extravagant scale, to pro- 
vide for even a majority of these sufferers ; therefore, it is the duty of 
those most prominently identified with their care not only to devise in- 
expensive methods, but firmly to oppose the present tendency toward 
extravagance and lavish display, which characterizes nearly all our 
public institutions. By the more general use of the tent we will more 
nearly conform to scientific principles and enlarge the scope and use- 
fulness of the modern treatment of tuberculosis. 

Whatever objections may be urged against the tent, it certainly has 
been proven that the housing of tuberculous patients in substantial 
buildings is not necessary in order to make them comfortable. 



SANATORIUM TREATMENT IN AN APPROPRIATE 

CLIMATE 

By Major G. E. Bushnell 
Fort Bayard, N. M. 



The institution for the treatment of tuberculous soldiers and sail- 
ors at Fort Bayard is often called a sanatorium. It will be noticed, how- 
ever, that this name is never given to it by army authorities. The 
official designation is the " U. S. General Hospital." It is a hospital 
rather than a sanatorium, for to it are admitted all cases of tuberculosis 
in the army and navy without reference to their prospects of cure. 
It is also a branch of the Soldiers' Home, an asylum at which dis- 
charged tuberculous soldiers may reside during their entire life, if they 
desire, but from which they may be discharged at their own pleasure. 
The term sanatorium as applied to this Hospital is therefore unfor- 
tunate if it leads to a comparison of results with sanatoria in which the 
cases are selected with a view to the exclusion of patients who are not 
likely to recover. 

The character of the patients is such as to render peculiarly diffi- 
cult the cultivation of the docility and patience so necessary for the 
attainment of cure. The military service naturally attracts the young 
man of a restless and reckless nature, fond of excitement and not given 
to over-anxiety as to his health. The sailor is perhaps even more diffi- 
cult to teach and restrain. He has the soldier's temperament and be- 
hind him the tradition that a day on shore is a day of license. It is 
true, military discipline may exercise restraint and compel obedience, 
yet in so chronic a malady as tuberculosis the cheerful cooperation of 
the patient is necessary to success, and some concessions must be made 
to his mental attitude. Personal study of a number of average cases 
who were given the most thorough instruction possible, showed that 
about one third of the cases were sufficiently open to conviction to be 
willing to take the proper care of themselves unwatched. 



NAT. ASS'n for study AND PREV. OF TUBERCULOSIS 363 

The soldier patient when granted his discharge from the army, 
usually after a period of about six months at the Hospital, almost in- 
variably proceeds at once to his home. If his case pursues a favorable 
course he may never return. Usually, however, he presents himself 
after an absence of several months in a distinctly worse condition than 
upon discharge. A system of selection is thus unavoidably in operation 
which practically insures the return of the less favorable cases. Sana- 
torium treatment under such conditions presents, it will be admitted, 
unusual difficulties. It is perhaps unfortunate, therefore, that the in- 
stitution which I have the honor to represent should be chosen to il- 
lustrate the treatment of tuberculosis in a favorable climate. There is 
no doubt that the climate is most favorable nor is there any doubt in 
the writer's mind that the results obtained at Ford Bayard are better 
with the class of cases treated than would be secured if the Hospital 
were located in an eastern climate. In justice to the climate as well as 
to our results too great emphasis cannot, however, be put upon the fact 
that very many of our cases are far advanced, even moribund, upon 
admission, so that we can never hope under such conditions to rival 
results obtained in even partially selected cases in a climate far less 
favorable than that of New Mexico. 

Fort Bayard is situated in the southwestern part of New Mexico 
on the slopes of a mountain range which projects southward like a 
promontory into the hot plains of the plateau which extends into 
Mexico. The latitude insures against extreme cold, the altitude of 6040 
feet puts a stimulus into the air and gives cool nights. The dryness 
of the air prevents lassitude even when the temperature is high. The 
slight precipitation permits sleeping out of doors with little or no pro- 
tection almost all the nights of the year. The rainfall which averages 
only 13.79 inches occurs chiefly in the summer months in the form of 
heavy showers usually in the afternoon, thus tempering the period of 
greatest heat and lending moisture to the air when it is most in need 
of it. In this respect the climate of New Mexico seems to be peculiarly 
advantageous. 

The altitude is considered mainly an advantage in that it secures 
tHe coolness requisite for stimulation. It guards against excessive heat 
just as the hot plains on the south guard against excessive cold. Pro- 
tection against both extremes of temperature is needed in the making 
of the perfect climate for outdoor life. 

The climate not only invites a return to outdoor life, it seems to 



364 NATIONAL ASSOCIATION FOR THE STUDY 

demand it. The general experience of physicans in the Rocky Moun- 
tain plateau is, I think, that those who live indoors, especially women, 
do not bear the climate well without frequent visits to a lower altitude. 
The usual and apparently obvious explanation is that there is a de- 
ficiency of oxygen in the thinner air of elevated regions such that the 
lack of it is more quickly felt when the air becomes impure. Speck,^ 
however, tells us that the organism cannot suffer in its metabolism 
from deprivation of oxygen at altitudes even considerably exceeding 
2,000 meters. 

The great increase in red blood cells in high altitudes as shown 
by the Thoma-Zeiss hsemocytometer is usually interpreted as represent- 
ing the effect of the organism to accommodate itself to the conditions 
arising from a scanty supply of oxygen. Schroeder ^ and other German 
writers have, however, seemed to demonstrate that the increase in the 
count of red cells is only apparent, being due to the lessening of atmos- 
pheric pressure upon the apparatus itself, and claim to show by other 
methods of investigation that the number of red cells is really only 
slightly increased or, it may even be disminished in higher altitudes. 
The late Dr. Curry found by the haemocytometer an average gain of 
1,723,400 red cells per cmm. in ten patients at Fort Bayard whose blood 
had been examined a few days previously at the U. S. General Hospital, 
Presidio of San Francisco, California. So large a gain in a brief period 
by sick men just after an exhausting journey would seem incredible 
unless we adopt the view of Schroeder that the gain after all was only 
apparent. My excuse for touching here upon a subject which so much 
needs further elucidation is to bring forward what theoretical reen- 
forcement I can to the view which I believe to be supported by expe- 
rience that the contraindications for altitude are to be found in weak- 
ness of the circulatory not of the respiratory functions. A climate 
which should demand the rapid production of almost countless millions 
of new blood corpuscles as a condition of existence would seem contra- 
indicated on theoretical grounds for patients suffering from exhaust- 
ing disease. Fortunately we are not obliged to admit the necessity of 
so severe a tax upon the organism in the process of acclimatization. 
The chief true contraindication for altitude is weakness of the heart, 
whether due to failure of the heart muscle, to uncompensated valvular 
lesion or to arterio-schlerosis. Owing to the increased strain upon the 

* Therapie der Gegenwart, 1901, p. 395. 

*Volkmann's Sammlung kl. Vortr'dge, Neue Folge, 338. 



AND PREVENTION OF TUBERCULOSIS 365 

heart, cases of very advanced tuberculosis recently arrived at a high 
altitude, undoubtedly succumb to the disease more quickly than would 
have been the case had they remained at a lower elevation. 

Many of the supposed evils of altitude are, however, believed to be 
due to over-fatigue. The arriving patient who has sufficient strength 
to bear the journey without exhaustion, feels at first the stimulus of 
the mountain air. It left to himself he will overdo and the first period 
of exaltation will be succeeded by a corresponding depression. It has 
been found at Fort Bayard that the average patient was very likely 
to get an extension of the pulmonary involvement during the first two 
months unless strictly watched. It is therefore now the rule to require 
patients to rest almost absolutely for the first month or more after 
admission, even though their lesions be comparatively slight and their 
temperature usually normal, and the results obtained fully justify the 
precaution. Even after acclimatization is complete, exercise must be 
pursued with more caution than at sea-level. It costs a little more vital 
energy to live at an altitude of 6,000 feet, and sick men who attempt to 
disregard this fact and exercise as freely as was their wont at a lower 
altitude, are likely to meet with disaster. We therefore give a wide 
scope to the indications for rest, and endeavor by preaching that, alas, 
too often falls upon deaf ears, to convince the patient of the wisdom of 
the restrictions with which his liberty is hedged. Yet in spite of all 
these efforts, overexercise still remains an even more potent cause of 
failure among our patients than dissipation. 

Officers of the army and navy as a class are carefully selected 
physically. Very few of them are naturally susceptible to a marked 
degree to tuberculosis. When they become tuberculous it is because 
they have become exhausted by physical and mental overwork, gener- 
ally under a tropical sun. In other words, in their cases the tuberculous 
infection is secondary to a nervous exhaustion, a neurasthenia. Treat 
the nervous condition secundum artem with rest, feeding and massage 
under the New Mexican sky and the tuberculosis often cures itself. 
Sometimes the treatment becomes unduly prolonged for the patience 
of the war and navy authorities, sometimes it meets with an obstacle 
in the inability of the patient to school himself to endure with patience 
the wearisome period of abstinence from the pleasures of life necessary 
for the perfect cure of the one as much as of the other disease, but 
on the whole the treatment of officers is much more satisfactory than 
that of the average enlisted man, pulmonary conditions being equal. 



366 NATIONAL ASSOCIATION FOR THE STUDY 

With the enHsted men the plan we are forced to adopt is to keep 
ambulant patients in check to a certain extent and by education to en- 
deavor to teach them to cooperate at least to the extent of acquiescing 
in restraint. To secure the necessary control patients are divided into 
classes which differ in degree of restraint. On admission the patient 
enters the receiving hospital and is required to rest out of doors almost 
constantly night and day except for the time needed for meals and 
toilet. After about two months, if the case does fairly well, the patient 
becomes an ambulant patient and is transferred to the tents. These are 
U. S. Army Hospital tents, framed and floored, and pitched end to 
end in series of three, each series accommodating twelve men. The am- 
bulant patients are subdivided into three classes: the worst class, 
men who have more or less fever or whose lesions are relatively large, 
are required to lie upon their beds an hour and a half in the morning 
and the same length of time before supper. They are called here 
" lying-down " patients. Seven out of 1 1 series of tents accommo- 
dating 84 out of 132 patients are " lying-down " tents. The second class 
occupy the remaining tents, but are not required, though they are per- 
mitted and encouraged, to rest upon their beds in the daytime. The 
third class occupy the old barracks, sleeping upon the porches in pleas- 
ant weather. As men of this class are more exposed to the vicissitudes 
of the weather and are sometimes driven inside by storms, the patients 
who compose it are selected from among the strongest. 

The great advantage of the climate, the possibility of sleeping out 
of doors, is utilized to the fullest extent. The tents are occupied 
throughout the year in all weather, the sides being kept up and the 
ends open during pleasant weather. In all but the worst weather it is 
possible to keep one end and one side open for ventilation. The porches 
are considered more desirable by the patients than the tents. They too 
are occupied the entire year save during severe storms. Even at the 
Infirmary to which faiUng patients are finally sent for complete rest 
in bed, the porches are used for the stronger men, one porch being open 
to the air save for the protection of roller curtains, the other shut in by 
glass in part and occupied at all seasons as a ward. A new ward for 
ambulant patients has just been completed which so far as the writer 
is aware constitutes a new departure in hospital construction, although 
the idea is an old one in the architecture of warm countries. The build- 
ing is rectangular in shape. In the centre is an open court. The sides 
of the court are dressing-rooms, the corners of the building being 



AND PREVENTION" OF TUBERCULOSIS 



367 



utilized for reading-room, toilet, storeroom, and office. The patients 
are required to sleep in the open air upon a platform adjacent to the 
wall of the building on all four sides of the court. This platform is on 
exactly the same level as the floor of the dressing-room with which it 
is practically continuous, and outer platforms also on the same level 
are built on the outside of the dressing-rooms. These rooms communi- 
cate with outer and inner platforms by numerous doors all wide enough 
to easily admit of the passage of a bed. By this arrangement each 
patient can move his bed or reclining-chair from inside to outside plat- 
form or the reverse and seek or avoid sun or wind at pleasure. A roller 
curtain of canvas on a skeleton porch can be lowered over the inner 
platform when needed to exclude rain or too hot a sun. The object of 
this mode of construction is, it is evident, to make sleeping out of doors 
pleasant by protecting from wind more effectually than would be possi- 
ble with any form of tent while at the same time affording perfect ven- 
tilation. 

Under the treatment of rest, open air and food, the newly admitted 
patient gains rapidly in weight. 



otiart ohonlne 3T>!rage Increase In iraifrHT of fuclrulant patl>into aft»r flxal odjalsalon to U.S. General Hospltea. 



















port 


Bayard, Vm Mexico, 
-^-arp-alTenia. nSTe'lol 


i^monf 


















Us. 


1 






on 


Int 


U I 
Snd 


T It S 
3rd 


4tll 


5th 


On 


Int 


2nd 


U 
Srd 


« T H 

4t» 


Sth 


eth 


7 th 


8 th 


141 1*3. 
































y 


140 Iba. 






























^ 




IM lbs. 














^ 










/ 










, IM lbs. 








/ 


/ 








/ 


r 














1.17 Ibn. 






/ 












/ 
















ISS lb3. 






/ 










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, l.^n lbs. 
















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l.-,4 1^1. 
















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133 lb3. 





































































368 NATIONAL ASSOCIATION FOR THE STUDY 

The chart shows graphically the average gain in weight in prima- 
rily admitted patients, the first curve representing the average weight 
of 128 patients for five months, the second that of 61 patients for eight 
months. These patients were all ambulant patients, the patients who 
after a preliminary period of rest at the receiving hospital are quartered 
in tents, and the chart therefor represents what may be expected to 
occur in patients of the better class under this regimen. Advanced 
cases which are treated as bed-patients in the Infirmary from the outset 
cannot of course be expected to improve as a class in weight under 
any treatment or in any climate. Except for the exclusion of Infirmary 
patients and of old cases readmitted, there has been no selection of 
cases in the preparation of this chart. 

The total number of cases of pulmonary tuberculosis treated in 
the year 1904 was 625. Of these 335 cases remained under treatment 
at the close of the year. The average daily number of cases under 
treatment from January ist to April 30, 1905 was 327. 

The 625 cases of 1904 gave the following results: — Arrested (or 
clinically cured) 12, 1.92% ; improved, 379, 60.64% ; unimproved, 173, 
27.68% ; died 61, 9.76%. Of these 625 cases, 120 had not been under 
continuous treatment or in other words were beneficiaries of the Sol- 
diers' Home who had been discharged and readmitted. Of this number 
14 died during the year 1904, three dying in the first week after read- 
mission, one in the third week, five others within the first six months. 
But one fatal case had been continuously under treatment for more than 
one year since readmission. These facts show clearly enough that such 
patients seek readmission for the purpose of securing a home for their 
last days rather than with any hope of recovery. Again light is thrown 
upon the hopeless character of many of the cases upon first admission 
by the fact that of the 47 deaths occurring in this class, 11 occurred 
within the first month, 22 between the 2nd and 6th months, and nearly 
all within the first year. The following table of duration of treatment 
gives the time of death in all fatal cases between January ist, 1904 and 
March 31, 1905. 



AND PREVENTION OF TUBERCULOSIS 



369 



Duration of Treatment in 78 Fatal Cases of PuLMoriARY Tuberculosis 
January 1st, 1904 to May 1st, 1905 





WEEKS 




MONTHS 


YEARS 


I 


2 


3 


4 


2 to 6 


7 to 12 


2nd 


3rd 


4th 


2 


7 


I 


4 


32 


10 


5 


I 




4 




I 




6 


4 

I 


I 
5 


5 


5 



Time of death in 62 cases under con- 
tinuous treatment 

Time of death in 16 cases not under 
continuous treatment : 

A. Reckoned from last admission 

B. Reckoned from original admission, 
in same cases 



62 

16 

(16) 
78 



A Study has been made of the cases received from the Philippines 
with the unexpected result that they are found not to differ materially 
as to prognosis from those originating in this country. This is probably 
due to the fact that the severer cases of tuberculosis die before they can 
be sent home from the Islands, whereas cases which occur at posts 
within the United States are sent to Fort Bayard almost without ex- 
ception. 

The small number of cases reported as arrested will perhaps ex- 
cite surprise. I cannot but feel, however, that the figures given hardly 
do the Hospital justice for the reason that the standard of health re- 
quired for return to duty in the military or naval service is much higher 
than that which would suffice to enable most civilians to begin again 
to earn a living. One thing is certain : the average patient who comes 
to Fort Bayard with a fairly recent and not too large lesion and with 
some degree of vital resistance will regain rapidly a good measure of 
health and will live on indefinitely under the' conditions that obtain 
there. Whether he will ultimately recover entirely will depend largely 
upon his good sense and patience. We are coming to understand that 
true recovery is a matter of years. With the advanced character of 
the cases with which we have to do, it would be idle to expect a large 
percentage of even apparent recoveries in a course of treatment which 
averages but little more than six months. I have recently been struck 
with the robust appearance of some former patients who on discharge 
could only have been classed as improved, but who have remained in 
New Mexico and have taken reasonably good care of themselves. Un- 
fortunately it has not been possible to keep in touch with discharged 



370 NAT. ass'n for study and prev. of tuberculosis 

patients so as to learn the final history of those who go away and do not 
return. 

Our most brilliant results are obtained in the treatment of officers, 
the class which most nearly resembles the patients who are treated in 
private sanatoria. By brilliant results are not necessarily meant com- 
plete cures, although one officer who came here on a litter and remained 
in bed nearly six months is now doing full duty in the Philippines and 
reports himself in perfect health. Many of the cases are too far ad- 
vanced to expect complete restoration to health, but patience, perfect 
rest, and outdoor life day and night the year round will often work 
wonders in most unpromising cases. 

The sanatorium, as has been well said, is a place for the education 
of the patient. We are carrying on our work with this end in view, 
and amid much that is discouraging ; believing that we can note prog- 
ress in our patients towards a better understanding, we look forward 
hopefully towards the future. 



THE TREATMENT AND CARE OF ADVANCED 
CASES OF PULMONARY TUBERCULOSIS 

By S. a. Knopf, M. D. 
New York 



The subject which the officers of the Committee on CHnical Medi- 
cine of our Association have assigned to me is indeed an important one 
and I approach it with great hesitation. In my humble opinion there 
is nothing in the whole domain of medicine which is more important 
and which demands from the physician more skill, more judgment, 
more perseverance, more patience, and may I add, more kindness of 
heart, than the treatment of advanced cases of pulmonary tuberculosis. 

The responsibility which rests upon the family physician treating 
a consumptive in the advanced stage is as great as, if not greater than, 
that of the surgeon in the presence of a patient on whom he is to per- 
form a difficult capital operation. There are more cases of advanced 
tuberculosis to be treated than any other disease ; and there is no con- 
dition more difficult to define than the one designated as advanced 
pulmonary tuberculosis. There is no disease in which the prognosis 
as to the time of the final issue is more difficult than in pulmonary 
tuberculosis after the incipient stage has been passed, for has it not 
been the experience of all of us that an apparently light and seemingly 
favorable case would be fatal within a few months, while a relatively 
advanced case would linger for years, or even get well? Again, there 
is no disease where so much can be done to render the patient com- 
fortable and hopeful as in pulmonary tuberculosis in the advanced 
stage. There is no disease where one case in a family can more readily 
become the cause of infection of other members, particularly in the 
stage when the consumptive begins to be confined to the close asso- 
ciation of the family members only. Again, in no other condition can 
the teachings and the guidance of the family physician be productive 
of so much good, even though the family may be predisposed to the 

371 



372 NATIONAL ASSOCIATION FOR THE STUDY 

disease under consideration. By the inauguration of timely prevent- 
ative treatment in such a family the disease can be limited to the one 
already afflicted, and all other members can be made strong and 
vigorous. Finally, there is no disease in which the successful manage- 
ment and treatment depend so much on the personal equation of the 
doctor as in an advanced case of pulmonary tuberculosis. 

By advanced pulmonary tuberculosis we generally understand all 
cases which can no longer be classified as incipient or early. I believe 
that by incipient we usually mean early cases in relatively young people ; 
and by early I mean, of course, a disease of relatively short duration, 
with a fairly good physique and nearly normal chest formation, with 
slight rise of temperature, a normal or only occasionally rapid pulse, 
the systemic derangement slight, cough and expectoration moderate. 
The physical examination reveals usually an involvement of only one 
side, an increased fremitus, a slight dullness on percussion, not extend- 
ing over the fourth or fifth rib anteriorly, and auscultation reveals the 
prolonged respiratory sound, rough breathing, sometimes cogwheel 
breathing, and rales of relatively less magnitude. Even if both apices 
are slightly involved and other conditions fairly good, we are justified 
in calling the case incipient, or at least early. 

To do justice to my subject, I must divide the advanced cases into 
two large classes, namely, ambulant and bed cases. Among the ambu- 
lant advanced cases I would place all those who are most of the time 
afebrile and in whom the systemic disturbances are only a little more 
aggravated than in the early stage, and who should be treated as in- 
cipient with the one exception that if there is a loss of weight instead 
of gain, or at least retention of their normal weight, they should be put 
at rest in bed or on the reclining chair, constantly exposed to the open 
air. I would make this condition sine qua non, whether there is fever 
or not, and to facilitate the metabolism and bring about a gain of 
weight I would have them massaged daily during the afebrile hours. 
Hydrotherapy should be used with all ambulant cases as a tonic and 
stimulant. The diet should be good and nutritious, of milk, eggs, meat, 
vegetables and fruit, in short, they should have the hygienic and die- 
tetic treatment the same as the incipient cases and their rest cure should 
alternate with properly gradated breathing exercises. In some the 
medicinal symptomatic treatment will have to be resorted to where 
aero- and hydrotherapy do not suffice to overcome increased cough, 
digestive disturbances, local pains, etc. It goes without saying that 



AND PREVENTION OF TUBERCULOSIS 373 

the advanced ambulant tuberculous case needs even more personal su- 
pervision, guidance and direction than an incipient case. Any impru- 
dence on the part of the patient may aggravate his condition beyond 
repair, and unless the family physician can see his ambulant tuberculous 
patient daily, or place him in charge of an intelligent nurse or a trained 
member of the family, such a patient would certainly be better off in 
a sanatorium. Unfortunately, there are not enough sanatoria for either 
rich or poor for this class of cases. In a number of cities in this 
country and in Europe we are treating them in our clinics and dis- 
pensaries. While owing to an insufficient hygiene at home, the result 
in these cases has been unsatisfactory, a fair amount of good has been 
accomplished through the work of the dispensaries, particularly when 
a system of regular visits by trained nurses to the homes of the patients 
has been connected with the dispensary treatment. The hygiene of 
the home and the dietetic management of the patients are, as a rule, 
materially improved by these trained coworkers of the dispensary 
physician. 

One thing, however, which we physicians and our health boards 
should bear in mind in regard to the management of these ambulant 
and advanced tuberculous patients is that they, when careless, really 
constitute the greatest danger. It is this class of patients who must be 
considered the most frequent source of infection. The careless, igno- 
rant, or helpless consumptive, when confined to his bed, is not likely 
to infect more than the four walls and the floor of his room, but the 
ambulant advanced case, being up and about, doing odd jobs or even 
following his regular occupation, can, if he is careless, disseminate his 
7,000,000,000 bacilli daily with the greatest ease. Of all the tuber- 
culous patients he should be the most disciplined and most carefully 
trained, and in many cases it is wise to tell him that by expectorating 
anywhere except in a proper receptacle he lessens materially his 
chances for recovery. The method of disposing of the expectoration, 
which experience has taught me they are most willing to abide by is 
not the pocket flask of metal or glass, or the pasteboard purse, but a 
method which will not attract attention to their infirmity. I advise 
these patients, if they are men, to have two pockets in their trousers 
lined with impermeable material, and when they leave in the morning 
to fill one with either cheap handkerchiefs or muslin cut in squares to 
look like handkerchiefs, and then use the empty pocket for the recep- 
tion of the soiled ones. These soiled cloths are to be burned on the 



374 NATIONAL ASSOCIATION FOR THE STUDY 

patient's return home. I advise the women patients to have a leather 
bag with two compartments and have them follow the same rule. 
Such persons must be urged always to wash their hands before touch- 
ing food. 

Another important item is to teach these patients that the moment 
they become feverish they must return home, and instruct them also 
what to do in case they should be seized by a haemoptysis. I make it a 
practice to tell all my patients that a pulmonary hemorrhage may hap- 
pen, but that it does not necessarily lessen their chances of recovery; 
and to the ambulant I add that, in case of a slight hemorrhage, they 
should go home and in a severe hemorrhage they should seek a place 
to lie down and send for a carriage to take them home or to a hospital. 

And now we come to the second class of advanced, or bed cases. I 
will subdivide these into four classes, namely, sanatorium patients, 
hospital patients, home patients — well-to-do, living either in cities or 
country, and the consumptive poor, living in villages or in city tene- 
ments. 

The treatment of advanced cases in a sanatorium has occupied 
the attention of sanatorium physicians in this country and abroad ever 
since Brehmer started the sanatorium treatment 50 years ago. There 
has always been a decided disinclination to receive patients in the ad- 
vanced stages into sanatoria, or even to keep cases when they are no 
longer considered favorable. There is, of course, a justifiable excuse 
for this policy, as there not being room for all, the advanced cases 
take up room that might be given to those who still have a good chance 
for recovery. The managers of pay sanatoria are always anxious to 
make a good showing, which is not possible when advanced cases are 
received or previously early cases allowed to remain after their con- 
dition no longer assured a favorable issue. It is usually stated also 
that advanced cases act as depressing factors on the rest of the pa- 
tients. Whether or not the policy just referred to is a wise or humane 
one I do not wish to judge here, but I know from personal experience 
that there is nothing more difficult in our own country than to find a 
sanatorium willing to take an advanced tuberculous patient, even where 
there are slight prospects of recovery. This is a sad condition of af- 
fairs, and I sincerely hope that existing sanatoria will either make a 
division for advanced cases willing to pay, or that special sanatoria 
for such cases may be established. 

How should such patients be treated and taken care of in a special 



AND PREVENTION OF TUBERCULOSIS 375 

institution? The general hygiene must, of course, be the same as in 
all well regulated institutions for the treatment of pulmonary tuber- 
culosis. If at all possible, each patient should have his own room 
and own veranda space, which should be arranged so that it can be 
separated by sliding doors. The room itself should have painted walls 
and such furniture as will permit of no accumulation of dust. The 
walls, floor and furniture should frequently be wiped off with cloths 
moistened in a sublimate solution of i to 3,000. The frequent wiping 
becomes particularly necessary in the latter stages of the disease when 
the patient is weak and becomes less careful to prevent drop infection 
through the so-called dry cough. As a receptacle for his sputum he 
should be provided with a porcelain or aluminum cup or flask par- 
tially filled with scented soap water. I prefer soap water because it 
renders the expectoration less visible and less repulsive to look at than 
when collected in clear water. Strong smelling antiseptic solutions 
are not necessary, since the cup is frequently emptied and the sputum 
destroyed, either by burning or by being poured into the water-closet. 
It is well known that the saprophitic organisms in cesspools and sewers 
destroy the tubercle bacilli. The Seabury and Johnson pasteboard 
sputum boxes with cover are also convenient as a receptacle for the 
sputum if the invalid is willing to use them. These boxes, removed 
with their contents from the frame, can easily be destroyed by fire. 
When the patient is yet strong enough to make use of the sputum 
pocket flask, he often prefers this to the use of the cup, for he can 
place the hermetically closed flask under his pillow, and on very cold 
nights, when he has to expectorate, he can do so without much effort 
and without being obliged to expose his back to the cold. 

When the patient has become too feeble to even make use of the 
light aluminum cup or pocket flask, moist. cloths should be placed 
where he can reach them easily and into which he may cough and ex- 
pectorate. In the last days of his sufferings it may become necessary 
to have a nurse constantly watching the patient to receive the sputum 
in the moist rags. These should, of course, always be burned before 
they have a chance to dry. 

Every patient should be provided with two handkerchiefs, one for 
the purpose of wiping his mouth after expectorating and to hold be- 
fore his mouth during the dry coughing spell, and the other for his 
nose. 

Fresh air must be given to all advanced cases, whether they are 



37^ NATIONAL ASSOCIATION FOR THE STUDY 

bed or ambulant patients. In the well equipped modern sanatorium 
this is done during the day by placing the patient in the reclining-chair 
on the rest-cure gallery. At night his bed is moved on to the veranda. 
In the special hospital for consumptives, with large wards and few 
special rooms, veranda space and rest-cure galleries are, as a rule, not 
of sufficient abundance to supply the demand. We must often content 
ourselves with well ventilated wards at night and during the day with 
a little solarium often altogether too crowded to be considered sanitary. 
In the future construction of special hospitals for the treatment of ad- 
vanced cases of tuberculosis it should be borne in mind that with more 
air space and facilities for open-air treatment, by day and by night, 
such symptoms as chronic fever, night sweats and persistent cough 
will be more easily controlled than with most of the antipyretics, anti- 
sweat and anti-cough products of our pharmacopoeia. 

One feature which is so frequently overlooked in the construction 
of special hospitals for advanced cases of tuberculosis is the necessity 
of a number of small rooms for dying patients, gangrenous cases, or 
patients where isolation is desirable or necessary for other reasons. 
The well-to-do consumptive living in a small town or village may have 
a sleeping shack, a Tucker tent, or a Bigg's tent house near his resi- 
dence for permanent quarters. All these are practical and easily con- 
structed and inhabitable throughout the year. These sleeping out-of- 
doors arrangements are, of course, of equal advantage for the open- 
air treatment in earlier cases. 

Another almost ideal way -of making a sanatorium installation in 
the home of the patient is to utilize the porch or to make an addition 
to one's house for this purpose. To show the facility of constructing 
such a sleeping-out veranda, allow me to quote from Dr. Trudeau's 
admirable article on " Sleeping Out of Doors," which appeared in the 
May number of Outdoor Life: 

" Ideal sleeping-out places of this kind are built out from a second- 
story room, and on them the comparatively well patient can sleep at 
night, or the bedridden invalid may spend the entire time out of doors 
and in close proximity to family and friends. The bed can be moved 
out at will on this little structure, and the patient can step at once 
into a room heated when necessary, to bathe or dress at any time, or to' 
get warm if chilled. f 

" These second-story sleeping-out verandas can be built at com- 
paratively small cost and attached to almost any country house, and 



AND PREVENTION OF TUBERCULOSIS 377 

the consumptive who for any reason cannot leave home, can do much 
to arrest and cure the disease by equipping his house with such an out- 
of-door sleeping-place, which will enable him to live at rest out-of- 
doors the year around, for in winter one step will take him into a 
warm room where he can bathe and dress in comfort. 

" The window of an ordinary second-story room is cut down to 
the floor and replaced by a door; the floor of the little sleeping-out 
porch is supported by wooden brackets attached to the sides of the 
house ; the two ends are boarded up with thin boards, with or without 
glass casings, supplied with dark shades ; an overhanging shingle roof 
completes the structure, and by its overhang prevents the rain from 
beating in directly on the patient. An awning is a great additional 
comfort against sun and rain. 

" When the invalid has selected an ordinary veranda for a sleeping- 
out place, his bed should be placed in a corner, if possible, so that he 
is sheltered from the wind on two sides, at least, and far enough back 
to prevent the rain from beating on the bed. One end of the veranda 
can thus, with a bed, a rug, a table and a chair, be turned into a sort 
of open-air room where the patient can spend not only the nights, but 
most of the days, as well. A slender bowed switch will do to attach 
the often indispensable mosquito net, or the entire end of the veranda 
can be screened off for this purpose." 

The open lean-to or " shack " is one of the best constructions for 
applying the open-air method when camping or in the country and at a 
distance from houses. Such a shack is practically like the sleeping-out 
veranda described above, with the house removed. It is closed on three 
sides, open in front, can be built of rough boards and roofed with 
rubberoid or some of the waterproof roofing papers, or shingled, as 
desired. Its depth should be sufficient, when combined with a marked 
projection of the roof, to keep the rain from beating in. If intended 
for cold weather, as well, it should have a small room at the back, with 
a stove, where the patient can get warm, wash and dress. 

The wealthy advanced tuberculous patient, desiring or being 
obliged to remain in the city, and so situated as to make the building 
of a shack or addition to his house an impossibility, must make a sana- 
torium of his home as best he can. He should choose for his bed and 
sitting room the lightest and best ventilated rooms of the house or his 
appartment. The half-tent, which protects him against the wind, the 
hot sun and the gazes of his neighbors, can be placed either on the 



37^ NATIONAL ASSOCIATION FOR THE STUDY 

roof, the extension, or in the yard. The comfortable redining-chair 
with the characteristic knee bend and adjustable back for taking the 
rest cure, which should be an indispensable article of furniture for all 
tuberculous patients, should be placed in the tent, and here the patient 
will probably spend most of his time during the day. This half-tent 
and the reclining-chair in the home of the well-to-do patient must re- 
place the rest-cure gallery of the sanatorium. For poorer patients the 
simple steamer chair and a few boards joined together to replace the 
costly half-tent will have to answer the purpose. A large and stout 
umbrella, such as is often used at seaside resorts, can be fastened to 
the back of the steamer chair and will answer the purpose where the 
tent cannot be provided. The poor patient will probably be obliged 
to resort to the roof for his rest cure, as the small yard of the tene- 
ment house, with many children playing in it, will scarcely be suitable. 
I do not favor the use of the fire-escape for this purpose. A recent 
conflagration in New York City, where many lives were lost owing to 
obstruction of the fire-escape, showed the dangerous results of evading 
the law in this way. 

For all tuberculous patients, and particularly for our consumptives 
obliged to remain in the city, we must seek to provide as much fresh 
and pure air as possible. In hot weather no one objects, as a rule, to 
having all the windows open, but in winter it becomes exceedingly 
difficult in the houses of the poor. In the hopes of solving this prob- 
lem in a measure, I devised an arrangement which I call a window 
tent. Through the kind cooperation of my former house physician at 
the Riverside Sanatorium, Dr. W. B. McLaughlin, I was able to pre- 
sent the first model of our modest invention at the meeting of the New 
York County Medical Society, last February. I recommended the tent 
first to a tuberculous physician living in Brooklyn and he reported such 
a marked improvement of all his symptoms that I have since suggested 
its use to a number of my colleagues. All have reported gratifying 
results. I recommended the tent in a case of pernicious anaemia and 
there was a marked improvement after a few days of constant exposure 
to the fresh air in the tent. The device not being patented, a number 
of out-of-town physicians have constructed the window tent themselves 
and have written me about their success with it, and suggested some 
improvements. To Dr. H. F. Stoll of Hartford, Conn., I am partic- 
ularly indebted for the idea of having an observation glass sewed into 
the canvas. A number of other modifications and improvements have 



AND PREVENTION OF TUBERCULOSIS 379 

suggested themselves to me by watching patients use the tent. With 
the help of Mr. Richard Kny, of the Kny-Scheerer Co., I have in- 
corporated these in a new model which I have the pleasure to present 
to you herewith. 

As you see, this window tent is an awning which, instead of being 
placed outside of the window, is attached to. the inside of the room. 
It is so constructed that air from the room cannot enter nor mix with 
the air in the tent. The patient lying on the bed, which is placed 
parallel with the window, has his head and shoulders resting in the 
tent. By following the description closely, it will be seen that the ven- 
tilation is as nearly perfect as can be produced with so cheap a device. 

In the lower half of an American window is placed the frame to 
which is attached the awning, stretched over a quarter circle, with a 
radius of 40 inches.^ The frame of the tent does not quite fill the 
lower half of the window ; a space of about three inches is left for the 
escape of the warm air in the room. By lowering the window this 
space can be reduced to one inch or less, according to need. On ex- 
tremely cold and windy nights there need not be left any open space at 
all above the window frame. The patient's breath will rise to the top 
of the tent and the form of the tent aids in the ventilation. The awn- 
ing is made of stout duck and is waterproof. 

The patient enters the tent through a flap which can be made 
either on the right or the left side of the tent. The lower edges of the 
canvas that come at the head and side of the bed are long enough to be 
tucked well under the mattress to exclude the air from the room and 
protect the patient from draught. The flap is so constructed as to ad- 
mit of easy access to the patient. 

The frame of the tent is composed of two lateral pieces which are 
attached to the inside portion of the windoV frame by four wing 
screws. The upper transverse portion of the frame of the window tent 
is made of telescoping galvanized iron bars, arranged so as to fit any 
window. The frame is placed in the frame of the window in such a 
manner as to permit the lowering of the window which may be essen- 
tial on unusually stormy days, and is always necessary for a little while 
in order that the room may become warm for the patient to dress, or 
to take his cold sponging, massage, etc. While in the tent the patient's 

*When there is a recess, so that the bed placed parallel to the window 
cannot be moved close to the window sill, the tent has to be made correspond- 
ingly longer and the bottom flaps made long enough to reach under the mattress. 



380 NATIONAL ASSOCIATION FOR THE STUDY 

body is kept thoroughly warm. In order to protect him from rain 
beating in his face, a Httle expansion awning can be fixed in the upper 
portion of the window. A roller shade has been placed in the window 
itself. This shade running from above downwards can be lowered at 
the patient's convenience to protect him from the too strong light or 
the gazes of the neighbors while taking his medicine, etc. The little 
expansion awning, or peak, of the tent is not always essential, partic- 
ularly if the house has a sufficient projection over the window, or the 
patient's room is located under the eaves in the upper story. 

The cot can be placed in the window to suit the patient's prefer- 
ence for sleeping on his right or left side, so that he has the air most 
of the time in his face. Another advantage of the window tent is that 
it will not attract any attention from the outside. Being placed along- 
side the window it will be convenient for the majority of the poor who 
have small rooms. If, however, the bed must be placed at a right angle 
to the window, the flap can be made in the middle of the tent. 

A piece of transparent celluloid is placed in the middle portion 
of the lent to serve as an observation window for the nurse or members 
of the family to watch the patient if this is necessary. It also serves 
to make the patient feel less outdoors and more in contact with his 
family. He can, if he desires, see what is going on in the room. 

If the window tent must be placed at a right angle to the window, 
the observation glass can be put in on the side. It goes without saying 
that, as a rule, patients should not smoke; when in exceptional cases 
this can be allowed, the danger of the celluloid window becoming 
ignited must be impressed upon them and the greatest caution urged. 
I prefer the celluloid observation glass to ordinary glass because it 
can easily assume the volted form of the rest of the tent and thus even 
the slightest possibility of air-pocket formation, above referred to, is 
done away with. Placing hinges in the upper part of the frame makes 
it possible, with the aid of a pulley, to lift the whole apparatus from 
the bed to any desired height. This will facilitate arranging the bed, 
sponging off the patient, or the application of a compress, massage, or 
any local remedy. 

If it is necessary to raise the bed to the height of the window-sill, 
it can be done with little expense. If the bed is of iron, a few addi- 
tional inches of iron piping can be attached to the legs by any plumber, 
or one handy with tools; raising a wooden bed can be accomplished 
with equal facility. If the window tent is to serve the patient only 



AND PREVENTION OF TUBERCULOSIS 38 1 

during the night, the tent can be pulled up and the bed can be moved 
away from the window during the day and the window closed. 

This window tent will, of course, be of greatest service to the 
consumptive sufferer in winter. If he is feverish, or his stay in bed 
is advisable, he can spend his entire time in the window tent. If the 
people are poor, and the room where the consumptive sufferer lies 
serves as living room for the rest of the family, the fact that the well 
members need not shiver and yet the patient can take his open-air 
treatment, is of vital importance in many respects. While the room 
will not be quite as warm as if the window was entirely closed, it will 
be much warmer than if there was no tent in front of the open window. 

Laying aside the economic advantages to a poor family when not 
being obliged to heat more than one room, the patient feels that he 
does not deprive his loved ones of comfort and warmth and that he is 
less a burden and hindrance to their happiness. The other members 
of the family, on the other hand, feel that they can give to the patient 
all the air he needs and that he himself need not suffer for their com- 
fort. 

In winter the patient's bed must be covered with a sufficient 
number of blankets to assure his absolute comfort and warmth 
throughout the night. Still, this covering should not be so heavy as to 
press down upon the body and make the patient feel uncomfortable 
and tire him. The light and tightly woven blanket is a better protec- 
tion than the loosely woven one. To the poor, whose disposal of blan- 
kets is, alas ! often very limited, it may be valuable advice to tell them 
ta put several layers of newspapers between the coverings. Outdoor 
Life, of December, recommends to have a dozen layers of newspapers 
sewed between two layers of flannel. This will certainly make a light 
and warm covering. In extremely cold weather the patient should, 
while sleeping outdoors, whether in a tent, shack, on the veranda, or 
in the window tent, wear a sweater and protect his head and ears 
with a woolen cap, shawl, or woolen helmet. 

Some patients will complain that the bright light awakens them 
too early in the morning and that they have difficulty in going to 
sleep again. In such instances I counsel the patient to have some light 
weight, but dark colored material (such as black lisle thread hose), 
to put over his eyes. This usually suffices to obviate the inconve- 
nience caused by the bright light. 

The pulmonary invalid should be provided with a bell to com- 



382 NATIONAL ASSOCIATION FOR THE STUDY 

municate with his nurse, relatives, or the friends who take care of him. 
He should, of course, have a small sputum cup or pocket flask handy 
to receive his expectoration. I prefer the flask for use in the window 
tent, for it seems to me that any kind of cuspidor which had to stand 
on the window sill would not be as safe as there is always a danger 
of its falling. A urinal should also be at the bedside so that the pa- 
tient will not have to leave the bed in the night. 

There is lastly one more advantage to be derived from the use of 
the window tent that is not to be underestimated. Patients who can 
only be persuaded with difficulty to sleep with the window wide open 
will not hesitate when they have this tent as an inducement. 

Besides the fact that the patient feels easier when he knows that 
the rest of his family are not in discomfort because he must be exposed 
to the cold, there is another advantage in this window-tent arrange- 
ment whereby the patient's physical and mental condition will be bene- 
fited. His prolonged rest cure in bed will be more endurable when he 
is permitted to look out on the street and watch life there than when 
obliged to gaze at the four walls of his room. 

When arranging for the rest cure on the reclining-chair during 
the day in the half-tent in the garden, on the veranda, in the sleeping 
shack, on the roof, or on the balcony, one should always bear in mind 
that it is much more agreeable and conducive to the well-being of the 
patient when taking the cure, to have a pleasant view to look upon. 
In building sanatoria, the greatest attention is paid to the proper se- 
lection of the place for a rest-cure gallery or veranda. The more pleas- 
ing and entertaining the outlook from these places the more certain is 
one to keep the patients quiet and restful. 

The aerarium, an invention of Dr. T. M. Bull, of Naugatuck, 
Conn., is another device for the open-air treatment, which is excellent 
where it can be applied. The aerarium is an awning covering the 
whole outside of the window and constructed of wood and canvas, 
painted the same color as the house. The following is an exact de- 
scription of Dr. Bull's aerarium as it appeared in the Journal of Out- 
door Life of October, 1904 : 

" The head of a cot bed is run through the window so that the 
patient's head and shoulders are outside. From the lower edge of the 
lower sash (which is raised about 20 inches), is suspended a heavy 
cloth or curtain which drops across the patient's body and effectually 
shuts off the room and thus permits the room to be warm. 



AND PREVENTION OF TUBERCULOSIS 383 

" In severe weather, the lower edge of the curtain may be drawn 
out to the sleeper's neck and his body will be practically indoors. In 
warm weather, the curtain may be drawn to the feet and his body will 
be practically outdoors. Windows may be inserted in the canvas to 
prevent obstruction of light to the room. 

" The sides are all closed. Air enters only through the floor in 
the slit between the bed and sides. (An extra floor with valve flaps 
is provided in case the rare backdraught occurs.) The air escapes 
only through the roof, a vertical current of air being thus assured. 
The top is composed of two superimposed roofs, the upper one foot 
higher and extending one-third as far as the lower. The sizes of the 
roof opening can be regulated." 

To the best of my knowledge Dr. Henry B. Dunham of the Massa- 
chusetts State Sanatorium at Rutland was the first to suggest making 
the patient sleep with his head outside of the window.^ Dr. Dunham's 
bed, projecting out of the window, in combination with the aerarium. 
may be feasible in a one or two-story house in a village or small town. 
Those of us familiar with the conditions of the consumptive poor in 
a large city will, however, agree on the difficulty of making such a 
device practical and popular among this class of patients. In a New 
York tenement house, for example, a cot protruding through the win- 
dow would attract unpleasant attention, and with the phthisiophobia 
that exists in many minds, the unfortunate sufferer might be obliged 
to seek other quarters. The cost of the aerarium will also bring it 
beyond the reach of the poor, and since the device is patented, it would 
be imprudent to endeavor to copy it with a view of producing a cheaper 
apparatus. 

Lastly, there is another device for bringing open air to the pa- 
tient which I saw for the first time at a recent visit to the Battle Creek 
Sanitarium. It is an invention of Dr. John H. Kellogg, the dis- 
tinguished director of that institution, and is called " Porte d'Air," 
or " Air Carrier." Dr. Kellogg's apparatus consists of a large flexible 
tube, through which the patient can receive fresh air from the window, 
whether sleeping or waking, resting or at work. 

The porte d'air has four parts. The flexible tube, which is ten 
inches in diameter, is made of strong cloth (denim or rubber-cloth), 
supported by steel rings about six inches apart. The window piece, 

^American Medicine, December 28, 1901. 



384 NATIONAL ASSOCIATION FOR THE STUDY 

which is about a foot wide, and of length equal to the width of the 
sash. This may be adjusted to fit different size windows. It is pro- 
vided with an opening the size of the tube, which on the inside is sur- 
rounded by a metal collar, to which the cloth tube is attached, and on 
the outside is covered by a door hinged at the top, and held open by a 
light spring. By means of a cord attached to this door, the amount 
of air entering the porte d'air may be instantly and perfectly con- 
trolled by the patient from any part of the room. The outlet or 
service end of the flexible tube, is furnished with a rigid metal collar 
by which it may be supported at the head of a bed, or over a cot, a 
chair, or a desk. It may be placed in any part of the room, and in any 
desired relation to the window, as it may be turned around a corner, 
or twisted in any shape desired, by simply connecting the supportmg 
rings. To the terminal opening or service end is connected a cloth or 
mackintosh hood for the purpose of directing the current of cold as 
may be desired. This may be used open or closed, or with one side 
raised, or in many cases it may be dispensed with. 

When the slight draught from the incoming cold air is objection- 
able, this may be obviated by removing the hood and covering the end 
of the tube with cloth. The air will find exit through the openings in 
the collar, and will be sufficiently diffused to prevent draught. 

The service which such an apparatus renders is, to my mind, of 
especial advantage when there is a severe rain or snow storm, when 
windows cannot be opened and the window tent or aerarium cannot 
be used. The air is brought from outdoors through the tube right over 
the patient's bed or his reclining-chair. Dr. Kellogg suggests the use 
of his porte d'air in summer; I can understand how it may render 
valuable service then. He supplements it by a small electric fan which 
is placed near an open window, and joined to the porte d'air by a fun- 
nel-shaped connection. This secures a constant current of air at any 
desired point. The air may be cooled while coming in by sprinkling 
the tube or By laying wet towels on it. 

I now desire to make a few additional hygienic and medicinal 
suggestions concerning the treatment and care of the more advanced 
tuberculous cases which are applicable to all, rich and poor, sanatorium 
and private patients alike. I have nothing new to offer in the way of 
symptomatic medicinal treatment, still less in the line of specific treat- 
ment. I will speak of what may be done to render our patients com- 
fortable in addition to the hygiene and aerotherapy already referred to. 



AND PREVENTION OF TUBERCULOSIS 385 

Every room occupied by the pulmonary invalid should have a com- 
fortable bed, a commode, and a comfortable reclining-chair, preferably 
one which will hold a mattress. If the patient is obliged to remain in 
bed all the time, or for a number of days in succession, it is best that 
he should have two beds — one for the day and one for the night. Of 
course, these should be single beds and with light metal frames. By 
thus changing beds the patient will be much refreshed and bedsores 
will be largely prevented. A small down pillow which may be placed 
under the small of the back adds much to the invalid's comfort. Pa- 
tients have assured me that nothing rested them so much as this little 
support which brings about a most grateful change of position. When 
tired of this position, the pillow can easily be removed. 

In ordinary weather, the patient in bed should wear a muslin 
nightshirt; in colder weather he may wear linen mesh underwear un- 
derneath and an additional outer garment, if necessary. I prefer the 
linen underwear because it produces a pleasant friction on the skin 
and dries quickly when the patient has perspired. The patient should 
be exposed as much as possible to the rays of the sun, in bed or on the 
reclining-chair, but with the head always in the shade. Fever is, of 
course, a contraindication to solar therapy. 

Judicious massage during the afebrile state is a valuable remedy 
to counteract lack of appetite, lack of assimilation, and a progressive 
atropy. The diet of the advanced tuberculous case should be ap- 
propriate to his condition. I do not believe in overfeeding the patient 
distressingly; it makes him uncomfortable and unhappy, and while he 
may thus add fat to his flabby muscles, the improvement in the pul- 
monary regions will never be concomitant. The patient should eat as 
much as he can without causing him distress. The food should consist 
of a mixed diet and be varied and appetizingly served. 

If there is a persistent anorexia, some tonic bitters are often help- 
ful, and in extreme anaemia the iron tropon as a food adjuvant has 
rendered me valuable services. When the ordinary iron preparations 
are not well borne and assimilated, ovoferrin often does good work. If 
the stomach is very irritable, trophonine may be given as a temporary 
nourishment, one to two tablespoonfuls three to four times a day. 

The patient's digestive tract must be kept in good condition. 
Washing out the mouth with some aromatic and refreshing solution is 
particularly indicated for the consumptive, who often complains of a 
bad taste in the mouth. He should use a toothpick and toothbrush 



386 NATIONAL ASSOCIATION FOR THE STUDY 

often; the latter should, however, have soft bristles, or be made of 
rubber. A coarse toothbrush is apt to lacerate the delicate gums and 
can do a great deal of mischief in the mouth of a consumptive where 
there are any number of pathogenic microorganisms. Another excel- 
lent way to clean the teeth without danger of injuring the gums is to 
rub them wi^h a bit of antiseptic cotton. With a little care this can 
be made very thorough and effective, and as a fresh piece can be used 
each time, it is preferable to a toothbrush which cannot be easily ster- 
iHzed. 

The bowels should be kept open by an appropriate diet, and, ex- 
cept in diarrhoea, plenty of good, pure water internally is always indi- 
cated. A diarrhoea, caused by injudicious overfeeding, must be treated 
by cleansing of the canal, by fractional doses of calomel, and a sub- 
sequent absolute rest and light diet. When the diarrhoea is due to tu- 
berculous invasion of the intestinal tract, an anti-diarrhoeic diet, con- 
sisting of rice, hard-boiled eggs, chocolate, mucilaginous soups, etc., 
is strongly indicated. As additional measures I recommend hot claret 
with cinnamon, tannine, bismuth and opium. If night-sweats cannot 
be controlled by outdoor sleeping, sponging with aromatic vinegar and 
water at bedtime and a light meal just before retiring, they may have 
to be combated by the addition of some atropin, agaricin, or eumydrin. 
But before resorting to active medication in hyperhydrosis I resort to 
two hydrotherapeutic means which have often rendered me most valu- 
able services, and which, to my mind, should always be preferred to 
medicinal treatment. The first is the wet compress. Several thick- 
nesses of rather coarse linen, folded in the form of a shawl, or, better 
yet, three different cloths, — one narrow one for each apex like a 
broad shoulder strap, and another wider one to wrap around the chest, 
— are soaked in water at a temperature of about 55° F., wrung out 
and then closely applied over the apices and around the thorax. A 
thick flannel band, somewhat wider than the compress, is wrapped over 
this, and the whole is fastened in place where it remains all night. The 
patient usually feels no discomfort, sleeps well, and sweats but slightly, 
if at all. In the morning the compress is removed, and the chest 
and shoulders are rubbed thoroughly dry. The second procedure is 
the sweat-bath. It can safely be applied when the patient is relatively 
strong and experience has demonstrated to the attending physician 
that it does not exhaust the patient to any severe degree. It will then 
almost invariably not only combat hyperhydrosis but will lower the 



AND PREVENTION OF TUBERCULOSIS 387 

patient's temperature and improve his general condition. Through 
the sweat-bath the excretory action of the skin is considerably in- 
creased, and a larger quantity of toxin is thus more rapidly eliminated. 
Frequency, time and duration of the bath must, of course, be always 
carefully controlled. A portable sweat-bath apparatus, which can be 
placed in the bedroom of the patient, is the most convenient manner 
to apply this hydrotherapeutic measure. In a publication by Dr. De 
Lancey Rochester, of Buffalo, on the Treatment of Pulmonary Tu- 
berculosis,^ I find that he as well as my friend. Dr. Charles G. Stock- 
ton of the same city, have also em.ploycd this method for a number 
of years, and with satisfactory results. Against severe haemoptysis 
an icebag over the heart, a little ice internally, quiet and morphine, 
and the ligation of the extremities are still our only resources. 

Carefully graduated breathing exercises, directed by the physi- 
cian, will help to overcome a dyspnoeic condition, facilitate haemop- 
tysis and indirectly facilitate expectoration. I have repeatedly pub- 
lished my exercises and I do not think it necessary to again describe 
them here in detail. I only wish to mention the necessary precaution, 
particularly when recommending them in the more advanced tuber- 
culous patients. These exercises should never be taken when there 
is an active febrile process, never when the patient is tired, nor to the 
extent of getting tired ; never after a hearty meal, never when uncom- 
fortably or tightly dressed, never in an overheated room or dusty or 
otherwise vitiated atmosphere. 

To control the cough we must use the well-known remedies, viz., 
disciplin, codein and heroin. Fever should, as far as practicable, be 
controlled by frequent partial sponging, and the heart-depressing coal- 
tar products should only be utilized as a last resort. The various 
serious symptoms arising from the secretions of the tubercle bacilli 
and their associates in the mixed infection can often be successfully 
combated by rectal injections of a normal saline solution for the pur- 
pose of absorption or by hypodermoclysis. Subnormal temperature is 
an indication for hot-water bags and hot lemonades, milk, weak teas, 
or hot mildly alcoholic drinks. Sleeplessness may usually be com- 
bated by gentle sponging with tepid water, a lukewarm bath before 
retiring, or the wet pack, but at times such substances as tryonal, 

* Rochester, Dr. De Lancey: 'The Treatment of Patients Suffering from 
Pulmonary Tuberculosis Who Cannot Go Away from Home." Medical News, 
February 25, 1899. 



388 NAT. ASS'n for study AND PREV. OF TUBERCULOSIS 

veronal, or even morphine, may become indispensable. The wet pack 
will often suffice to combat pleuretic and intercostal pains, but at 
times morphine alone will help to ease the sufferings, and I believe 
that in the last stages of consumption, when all hope of improvement 
must be abandoned, we should not be too sparing in the administration 
of morphine to render the patient comfortable and let him suffer as 
little as possible. 

The psychic treatment of the consumptive invalid in the latter 
stages of the disease is important. While many are sanguine, not a 
few are morose and need encouragement and kind and hopeful words. 
Should we tell the absolutely hopeless bluntly that there is no hope 
for him? I do not believe that this is necessary, as a rule. He can 
be told to arrange his affairs and still we need not deprive him of all 
hope. Many of this kind hardly ever realize their true condition and 
would not believe us would we tell them the truth, for it is an un- 
doubtable fact, borne out by the experience of many, that, owing per- 
haps to the extreme toxicity of the blood, there seems to be a sort of 
general anaesthesia without involvement of the mental faculties. 

As in the hygienic, dietetic and medicinal treatment of the con- 
sumptive, the individual must be considered and no routine treatment 
can ever be successful, so must every consumptive's mind be treated 
as a distinct entity. No two are alike. We can do a world of good 
to our consumptive fellowmen who are no longer in the earlier stages 
by prolonging their lives and making them comfortable and even 
happy and useful. History is full of instances where the most beauti- 
ful work Has been accomplished by men in the declining stages of 
consumption. It lies thus with us, when in the presence of an ad- 
vanced case of pulmonary tuberculosis, to do good, not only to the 
individual, his family and friends, but even to the world at large. But, 
as stated at the beginning of my lecture, we must bring to this work 
a careful study, a keen intelligence, much patience, forbearance some- 
times and firmness at others, but always our whole heart. 



HOME TREATMENT OF TUBERCULOSIS EITHER 
IN FAVORABLE OR UNFAVORABLE CLIMATES 

By Edward O. Otis, M. D. 

Boston 



My title, strictly speaking, is a misnomer, for no climate in which 
we treat tuberculosis is altogether unfavorable. More correctly one 
should say in " less favorable and more favorable climates." The 
meaning, however, is plain : the unfavorable climate refers to the treat- 
ment of the patient at or not far from his place of residence, which, 
generally speaking, possesses a less favorable climate; the favorable 
climate refers to a resort or place of residence selected for its supposed 
possession of especial climatic factors favorable for the cure of tuber- 
culosis, the patient removing to the resort for the express purpose of 
availing himself of its favorable climate. In both cases, the treatment 
is conducted individually, privately so to speak, in contradistinction 
to sanatorium treatment. 

When one considers the enormous number of tuberculous indi- 
viduals in the country, the state, the city or town of his residence, he 
reaUzes that the vast majority of them must be treated at home if 
treated at all. It is probable that we shall never multiply sanatoria to 
such an extent that a tithe of the consumptives can be accommodated 
in them even if they all desired to be. According to Osier, probably 
not two per cent, of the cases can take advantage of the sanatorium 
or climatic treatment. 

Four divisions can roughly be made of those consumptives who 
must or will be treated at home, that is, not in special institutions. 

First: The desperately poor, the majority of whom are in the 
cities, but some also in the country; those who cannot themselves or 
through friends or charity obtain the means for sanatorium treatment, 
and, furthermore, who must work up to their physical ability or bevond 
for the absolute necessities of life. 

389 



390 , NATIONAL ASSOCIATION FOR THE STUDY 

Second: Those who are in more favorable circumstances while 
they work, but whose income ceases on cessation of work. They also 
must be treated while they work, up to a certain degree, or if through 
the exertions of the members of the household they can remain at home 
for a season without labor, they cannot afford the expense of a resi- 
dence in a climatic resort. 

Third: Those able pecuniarily to go away, but who from a 
strong disinclination to do so, or from domestic or other reasons are 
not able or do not wish to do so, and desire to take their chances at 
home. 

Fourth: Those able and willing to go to a health resort, and do 
so, but prefer to be treated privately and not enter a sanatorium, even 
if one existed in the place of their choice. There may be added to this 
class those, mostly young men, who, though without means, are enabled, 
one way or another, to transport themselves to one of the more favor- 
able climatic regions, Colorado, Texas, New Mexico, Southern Califor- 
nia, etc., and there obtain some employment sufficient for their support. 
They do not obtain much treatment, home or any other kind, but with 
the occasional advice of a physician they not infrequently make sur- 
prising recoveries, and all of us have known such happy results. This 
may be called home treatment conducted by the patient himself. 

One is tempted to add a fifth class of those who are able and will- 
ing to go away or do anything, but whose attending physician prefers 
to retain them under his own immediate care and treatment, for what- 
ever reason it may be. This class often seeks or is sent to a climatic 
resort when the disease has so far progressed that the change is useless. 

Each of these classes must, in a measure, be treated differently, or, 
better, receive a different application or a modification of the same 
broad principles of the hygienic-dietetic treatment, dependent upon 
their environment, social and material condition, and individual char- 
acter or temperament. 

In what I have to say as to the home treatment of these various 
classes, I shall suppose that the cases who come under treatment are in 
the early stage of the disease, or offer a favorable outlook for the ar- 
rest of it. Advanced cases of whatever class can best be cared for at 
home or in a consumptive hospital. 

First, the very poor in the city or country, the larger number of 
whom are the tenement-house dwellers of our cities. 

The lot of the consumptive from this class is a sad one, but not 



AND PREVENTION OF TUBERCULOSIS 39 1 

hopeless. Much has been and can be done for him. The tuberculosis 
dispensary and the tuberculosis association in our large cities are doing 
admirable work. Excellent work also is done by the private physician 
with a great love for his fellowman and a great enthusiasm in the new 
treatment, and in his quiet way he accomplishes much and may justly be 
proud of his results. The patient himself, when once he is made to re- 
alize the value of the treatment, is a staunch cooperator. Every poor 
consumptive in our large cities can now receive a careful examination 
either at a tuberculosis dispensary or general hospital or out-patient de- 
partment, and be instructed in the way of the " cure " applied according 
to his limitations ; and here comes in the value of the visitor or district 
nurse who goes to his house at stated periods and personally investi- 
gates his condition, and, so far as possible, puts and keeps him on the 
hygienic highway. 

The diet kitchen, or other charitable associations, will aid in the 
matter of proper and sufficient nourishment. And here let me say that 
in dealing with patients of this class, I have become profoundly con- 
vinced that our supreme effort should be directed towards the nutrition. 
Feed the patient. See that somehow he obtains the requisite amount of 
nourishing food. In my experience, patients of this class are almost 
invariably underfed, and what they do eat is often unwholesome and 
unnutritious — cake, pie, tea, and the like. I am convinced that we 
have been placing proportionately too great emphasis upon the open- 
air treament and too little upon the side of the nourishment. What 
avails the reclining-chair and the sleeping out of doors if at the same 
time the food supply is inadequate to the needs of the patient and the 
disease, and is of an inferior quality and badly prepared? Let me have 
a decent bedroom which affords a fair amount of fresh air, the means 
of providing good and sufficient nourishment, and I believe I can show 
better results than the most perfect arrangements for the open-air life 
accompanied with indifferent or insufficient feeding. We shall never, 
in my opinion, make much headway against tuberculosis among the 
tenement-house dwellers or the very poor until me devise some adequate 
means whereby these poor consumptives can be properly and fully fed. 

I believe Burton-Fanning is entirely correct when he asserts that in 
many cases the only thing wanted to promote restoration may be the 
improvement of the patient's nutrition through the agency of an altered 
(i. e., an increased) dietary [" Diet in the Treatment of Pulmonary 
Tuberculosis." The Practitioner, January, 1905.] 



392 , NATIONAL ASSOCIATION FOR THE STUDY 

The best room in the tenement for air and light can be selected for 
the patient's bedroom, and it is possible to make it and keep it hygienic- 
ally clean. Even under tenement-house conditions, oftener than one 
thinks, a means of sleeping out of doors can be found. A tent house on 
the roof can be arranged, as one of our Boston patients cleverly did, or 
a platform outside of the sleeping-room, as in Dr. Millet's well-known 
case. 

When once our poor patient realizes the danger, he can avoid a 
thousand unhygienic exposures — a crowd in an unventilated room, ex- 
cesses of every kind, over-exertion so far as necessities will allow, loss 
of sleep, neglect of regular eating, and bathing, etc. On the other hand, 
he can utilize to the utmost his limited opportunities for rest, a cold bath 
in the morning, a glass of milk between meals instead, perchance, of his 
glass of beer. He can spend his holidays in the park. His family, 
moreover, can often be made willing and eager coadjutors in the 
treatment. 

In this class of cases, I believe judicious medication plays a more 
important part in the treatment of patients who are under more fa- 
vorable conditions. Tonics, such as arsenic, creosote, cod-liver oil and 
the like, and the medical treatment of symptoms as occasion requires, 
can be, and have in my experience been, of service. At all events, we 
shall be unable to hold many of our patients unless we do give them 
some medicinal treatment. 

As the patient makes his regular visits to the dispensary, he is 
weighed, his temperature taken, and a general estimate is made of his 
progress. From time to time, also, the nurse makes her report of his 
home conditions and life. 

If the patient is able and obliged to work, he can not infrequently 
make for himself in his shop or factory, or if a housewife in her home, 
better hygienic conditions when once the importance of so doing is 
realized, or the work may be changed for better conditions of light, air 
and cleanliness. It is sometimes quite surprising how well a consump- 
tive patient will do and at the same time remain at work, and it can par- 
tially be accounted for, I think, from the fact that the natural vigor of 
the working class is greater than that of those higher in the social scale, 
as attested, for example, by the greater fecundity of the women and the 
ease with which they endure their many pregnancies. Large families 
are the rule with the women of this class. 

If fever exists and rest is indicated, a serious and often insur- 



AND PREVENTION OF TUBERCULOSIS 393 

mountable difficulty arises. If by any chance the patient is enabled to 
lay off and take a period of continuous rest, he can take a deck chair, or 
two common chairs using one for his feet, and go up on the flat roof of 
his house or in the brick rear yard, or if in the country anywhere out 
of doors. While he is thus lying out, the head can be protected from 
the sun and wind by an improvised awning or a screen. If he cannot 
give up his work, we must take the chances or try to procure for him 
an entrance into a sanatorium, but the outdoor sleeping at night and all 
the fresh air he can obtain by day, together with abundant nutrition, 
will often under these adverse conditions not infrequently avail in caus- 
ing a subsidence of the fever. 

With the second class we have larger opportunities with which to 
work. If the residence is not already in the country, the suburbs of a 
city or in an adjacent country town, as is so frequently the case with 
this class, a change to a location where the residence has open space 
about it is often possible, and, in consequence, the establishment of the 
open-air life is more readily and completely effected. Moreover, 
sleeping in the house with open windows, under such circumstances, 
with purer and freer movement of air, is obviously a great advantage 
over city bedroom air. (The application to the windows of such in- 
genious contrivances as the so-called " Aerarium " or Dr. Knopf's win- 
dow tent, which covers the head, practically allows one to breathe out- 
door air while the body is kept warm indoors. This arrangement can 
also be made use of in a tenement-house, as Dr. Knopf suggests. If the 
rest-cure is indicated, one of the small shacks or shelters can be set up in 
the yard, or, as a country house generally has a piazza or porch, that 
may be utilized for the purpose.) 

The nutrition, which is the more important part of the treatment, 
must be carefully prescribed and a daily menu prepared, inexpensive it 
may be, but rich in proteids, carbo-hydrates and fats. 

It is well for the patient to keep a record of his daily temperature, 
pulse, weekly weight, amount and kind of food taken, and notes upon 
his various symptoms, such as cough, expectoration, sleep, appetite, 
etc. If no active symptoms exist and the general condition is good, 
the patient may follow certain employments, under the watchful eye of 
his physician, making shorter hours and under favorable hygienic con- 
ditions, such as good ventilation, light, etc., if he works indoors. 

The writer has under his care at the present time a young 
draughtsman with slight disease at one apex, in good general condition 



394 NATIONAL ASSOCIATION FOR THE STUDY 

and no fever. He has attendee^ to his occupation all winter, but has 
otherwise carried out the hygienic-dietetic treatment ; he has gained over 
twelve pounds, and is apparently making a successful recovery. He re- 
sides in the suburbs at home, where he can have comparatively pure air 
and proper nourishment. When out of his office, he avails himself of 
every opportunity for fresh air and avoids all gatherings indoors and 
over-fatigue. 

Osier in a few words thus sums up the essentials of the home treat- 
ment in the small towns, country places and the suburbs .of our large 
cities, and it can well stand as an epitome of the home treatment in gen- 
eral. He says : " First, the confidence of the patient, since confidence 
breeds hope ; secondly, a masterful arrangement on the part of the doc- 
tor; thirdly, persistence — benefit is usually a matter of months, com- 
plete arrest a matter of years ; fourthly, sunshine by day, fresh air night 
and day ; fifthly, rest while there is fever ; sixthly, breadstuff s and milk, 
meat and eggs." 

With the third class, those in easy circumstances but who can or 
will not go far away from home, we are in the position to avail ourselves 
of everything which will make the home treatment as perfect as possible. 
If the residence is not in the country, a country home can be acquired 
and its situation selected with direct reference to its fitness for the open- 
air treatment. It can also be especially equipped for this purpose. If 
the patient has active symptoms, and especially if a woman or child, the 
employment of a nurse experienced in the treatment, at least for a time, 
is to be strongly advised. Such constant supervision and education in 
the detail of the cure is invaluable, and the physician is kept informed 
of the progress of the disease with a minuteness and definiteness not 
otherwise possible. Moreover, the companionship and encouragement 
of an agreeable and inspiring nurse is of no small value, and she will be 
of exceeding value in insisting that the nourishment is properly pre- 
pared and taken in sufficient quantity. 

It is frequently possible and often wise to send a patient of this 
class for a brief period to the sanatorium that he may thoroughly learn 
the plan of the hygienic-dietetic life which he is to follow later. No 
amount of teaching will so well do this as doing it himself and seeing 
others do it in the sanatorium. 

The rest-cure by day and the open-air sleeping by night can be sat- 
isfactorily arranged for by a shelter, shack or piazza facing south, 
southeast, or southwest, and if needed, protection from wind may be 



AND PREVENTION OF TUBERCULOSIS 395 

secured by movable awning, screen or similar device. If the piazza 
or veranda opens from the patient's room, the patient, even if he has 
fever, can be easily moved out upon it. 

If a room is used for sleeping, it should be large with a number of 
windows and an open fireplace. The furnishings should be few and 
plain, and capable of easy removal and cleansing. It is not necessary, 
however, to convert the room, as Minor says, into a species of cell with 
four bare walls, a bed and a chair. The bed should stand out in the 
room that a good circulation of air may be secured. If, in addition to 
the open fireplace, furnace heat is required, as is commonly the case in 
our northern latitudes, a porous pot of water may be hung under the reg- 
ister, and the dry furnace air can thus be moistened as it enters the 
room, giving it a more natural and agreeable atmosphere. The bed 
covering should consist of blankets or down puffs, and only as much as 
will keep the patient comfortable. 

A reclining-chair with a movable back and a curve for the knees, 
and well upholstered, is used for the open-air rest-cure, which is 
indicated when a temperature of 100° or over is present. 

If the patient is afebrile, a walk once or twice a day from one-half 
to two hours, according to the result as shown by the temperature, may 
be taken. 

While lying in the reclining-chair, the patient can read, engage in 
some simple handiwork, such as basket weaving, carving, and the like ; 
or, if he is fortunate enough to have a pleasing landscape before him, 
enjoy the view. Games with other patients can also be indulged in. 
Much talking and visiting are generally a useless expenditure of 
strength. 

In the patient's bedroom or an adjacent bathroom, which is warm, 
the cold morning sponge bath can be taken. ♦ 

The physician who has his patient under the care of a nurse, or 
who has trained him to keep a record of his own case, may, when the 
disease is progressing favorably, find a visit once in several days suffi- 
cient. This, however, will depend upon the state and activity of the dis- 
ease as well as upon the character of the patient ; frequent visits may be 
deemed advisable simply to inspire and encourage him. 

When the home treatment has been fully established and the neces- 
sary equipment installed, a detailed programme or daily routine should 
be written out subject to such modifications as change occurs in the 
condition of the individual or the disease. 



39^ NATIONAL ASSOCIATION FOR THE STUDY 

A sug-gestive jour medical for the average patient, whose gen- 
eral condition is favorable and who is afebrile, may be as follows : 

In the morning on arising, a hot glass of milk, bouillon, or a cup 
of weak coffee with cream ; then a cool or cold sponge bath in a warm 
room ; and then to be dressed. 

7.30 to 8.30 A. M., breakfast, consisting of weak tea, coffee or 
milk, a cereal with cream and sugar, fried bacon, a poached or boiled 
tgg, bread and butter. For the tgg may be substituted a chop, steak, 
minced meat, sweetbreads, chicken, etc. 

9 to II or 12 A.M., exercise when permissible, generally a 
measured walk. 

11 A. M., a glass of milk or malted milk, oat meal gruel, bouillon, 
or raw tgg. (These and the other between-meal nourishments may be 
omitted if the patient is in a good condition and takes three good meals 
a day.) 

12 to I P. M., rest in a reclining position. 

I to 2 P. M., dinner, consisting of soup, rare roast beef, mutton, 
lamb or fowl; vegetables, such as potatoes, spinage, tomatoes, peas, 
beans, corn, asparagus, etc. ; salad with olive-oil dressing ; a simple des- 
sert ; fruit ; and, if desired, a small cup of black coffee. After dinner, 
rest for one half hour. 

3 to 4 or 5 P. M., exercise if permissible, generally a walk. 

4 P. M., milk with cracker, bread and butter, bouillon, milk or 
malted milk, or raw tgg. 

5 to 6 or 7, rest in a recumbent position. 

6 to 7, supper ; one warm dish, meat, fowl, minced meat, boiled rice, 
a cereal, bread and butter, tea or cocoa, cooked fruit or marmalade. 
After supper, rest on the piazza or in a room with the windows open. 

9 o'clock, a glass of warm milk, bouillon, malted milk, or Mellin's 
Food. 

9.30 to 10, to bed. 

After each meal the mouth and teeth should be thoroughly 
cleansed. 

It goes without saying that the most painstaking care should be 
taken in the proper destruction of the sputum, and whatever is used by 
the patient, his bedclothes, eating utensils, etc., should be reserved 
for him alone and separately washed. Once a week the bedroom should 
be thoroughly cleaned. (Mental quietude and cheerful expectancy is 
to be cultivated in the patient, and herein the personality of the physi- 



AND PREVENTION OF TUBERCULOSIS 397 

cian means so much. He must be schoolmaster and inspirer as well as 
clinician, as some one has said, and cultivate a " merry heart which 
maketh a cheerful countenance, and doeth good like medicine." 

Finally, with the fourth class we have a new set of conditions to 
deal with — the home treatment in a new climate. Old associations, old 
habits, the accustomed environment, are all exchanged for new scenes, 
new habits and unaccustomed surroundings. Indeed, one of the bene- 
fits of a radical change is that old habits of life are broken up and new 
ones substituted. No radical change of this kind is to be unadvisedly 
or lightly entered upon, but discreetly, soberly and advisedly. And yet 
even to this day, one often finds patients sent far afield in the most 
haphazard way. Perhaps most frequently the patient goes on his own 
responsibility, or on the advice of friends, and so long as human nature 
is as it is, I suppose this will always happen to a greater or lesser extent. 

In determining the question of a change of climate, the principal 
points to be considered are, first, the exact condition of the patient and 
his disease. Second, the climate best suited to him and his disease. 
Third, the condition of the resort selected which possesses the climatic 
factors desired, such questions as the sanitary condition of the place, the 
accommodations, possibility of obtaining good food and of finding a 
reliable physician are all to be determined. Fourth, the influence of 
the change and climate upon the relatives or friends who will accom- 
pany the patient. Fifth, the material or pecuniary condition of the 
patient : can he conveniently afford to make a long sojourn away from 
home without pecuniary worry ? 

When once, however, the resort which seems most suitable for the 
case has been selected, the name and address of a reliable local physi- 
cian is to be obtained, and he should previously be communicated with 
and given an outline of the case. He also will advise as to the selection 
of accommodations, which should be secured beforehand. It is to be 
borne in mind that at the present time in very many health resorts, 
neither hotels nor boarding-houses will receive tuberculous cases, and 
hence the importance of arranging beforehand the engagement of ac- 
commodations. Often the local physician controls one or more proper 
boarding-houses which are exclusively used for tuberculous cases. Or 
a housekeeping establishment will have to be set up. 

On arriving at the resort, the local physician should at once be 
visited, and from that time henceforth the patient should be under his 
immediate care and control. Any attempt of the home physician to 



398 NATIONAL ASSOCIATION FOR THE STUDY 

control or direct the treatment at a distance is pernicious. It is neither 
just to the patient nor reflects any credit on the home physician. 

When once the patient is established in his new home, the daily 
routine and treatment will be the general hygienic-dietetic open-air one 
as has been described under the third class, and the admirable exposi- 
tion of this home treatment in a favorable climate by Minor of Ashe- 
ville,^ Gardiner of Colorado,^ Solly and others, leaves but little to add. 

I do, however, desire to utter a word of caution regarding the gen- 
eral advocacy of pulmonary gymnastics. While it may be true that un- 
der the skilled direction of experts, such exercises may be taken with- 
out injury or risk, and the safe time of taking it in the course of the 
disease can be wisely chosen, to generally advise such exercise, in my 
opinion, is unwise and not without danger. Moreover, I am by no 
means convinced that any time in the course of the cure pulmonary 
gymnastics do not do more harm than good. I am rather of the 
opinion held by Bridge and others that it is rest — restriction of motion 
— we desire for the diseased lung rather than increased motion. 

Of course, the weak point in the open-resort treatment is the ever 
present danger that the patient will not keep himself strictly under the 
constant supervision of the physician, especially when he finds himself 
improving, and the latter does not possess the same power of com- 
pelling obedience which the sanatorium physician does. The sana- 
torium patient is like the soldier of the regular army, obliged always 
and ever to obey unquestioningly his superior officer, while the 
home patient is like the militiaman over whom his superior officer has 
but a partial and intermittent control. Whether or not, however, we ad- 
mit that any home treatment, even at its best, can equal that of a well 
conducted sanatorium, we have to accept the fact that the great mass of 
consumptives, at least in this country, will and must be home-treated, 
and, consequently, it is the part of wisdom with us, not to say a duty, 
to perfect and develop the home treatment so that we may obtain from 
it the best possible results. 

* " On the Feasibility and Management of a Hygienic Cure of Pulmonary 
Tuberculosis outside of Closed Sanatoria," by Charles L. Minor, M. D., New 
York Medical Journal, Dec. 21, 1901, and Jan. 11, 1902. 

*"The Care of the Consumptive," 1900, G. P. Putnam's Sons. 



AND PREVENTION OF TUBERCULOSIS 399 



GENERAL DISCUSSION ON THE SYMPOSIUM ON SANATORIUM 
TREATMENT AND OTHER PAPERS 

Dr. DeLancey Rochester, Buffalo: I wish to commend most 
highly the admirable papers of Drs, Knopf and Otis on the home 
treatment of such cases as are unable to avail themeselves of sana- 
torium care. There are a few points I wish to emphasize and a few 
that I wish to add. I think it of great importance that we write out 
the directions for our patients. It would be of much more benefit to 
spend time in writing out directions as to mode of life rather than to 
spend it in writing prescriptions for medicine of doubtful value. The 
value of fresh air, sunshine and good food cannot be overstated — at 
the same time in order that the food may have its full nutritional value 
it is of especial importance that the functions of excretion be looked 
to. The occasional use of laxative medicines and the more frequent 
use of bowel washes to flush the colon should not be neglected. One 
of our greatest organs of excretion is the skin and it is of utmost 
necessity that it should be kept in good functionating condition — 
carefully prescribed baths, suitable to the individual cases, should not 
be neglected, and the hot-air sweat — induced in the afternoon — has 
in my hands, in a number of instances, prevented the occurrence of the 
night sweat and has made the patient much more comfortable. 

I wish to insist upon the absolute necessity of careful medical 
supervision and that it is therefore incumbent upon us when we send 
a patient away to give him a letter to some competent physician in the 
locality to which he goes. 

The sanatorium treatment is of especial value from an educa- 
tional point of view. Daily observation of and participation in the 
thing done act as clinical lectures in impressing the procedure upon 
the patient. Patients have learned what fresh air means and they will 
not be content at home with the window opened an inch or two; it 
must be wide open. We must get over our fear of drafts — and there 
is no harm in a draft provided we are properly clothed to withstand 
the wind. 

In every locality it is advisable if possible to have two sanatoria 
— one for incipient and one for advanced cases — and I heartily agree 
with Dr. Foster that every case should have the privilege of sana- 
torium treatment if desired and that all cases who are either unwilling 



400 , NATIONAL ASSOCIATION FOR THE STUDY 

or unable to properly care for themselves at home should be sent to 
one or other of these sanatoria and that the local health authorities 
should have the power to commit such cases and make them remain 
in the institution so long as it is necessary to protect the community 
from contamination. The punishment of these individuals for dis- 
obedience is a serious problem. I believe they should not be sent to 
jail, but I am at a loss how to manage them. The value of such 
administrative control has been demonstrated in New York during 
the last two years. 

Dr. S. A. Knopf, New York: I would like to qualify what has 
just been said by Dr. DeLancey Rochester regarding the importance 
of giving written instructions to patients about diet and hygienic rules 
in general. Printed instructions are not nearly so emphatic, and in 
my clinic where, owing to pressure of time, we are obliged to have our 
instructions printed, I urge my young colleagues always to accompany 
the handing of the printed leaflet to the patient with some verbal 
instructions. 

I regret that the two gentlemen whose excellent papers we are to 
discuss are not present. I refer to Drs. Clapp and Foster. Dr. Clapp, 
in his paper on " What Cases Are Suitable for Treatment at a State 
Sanatorium for Tuberculosis in New England ? " mentioned two con- 
ditions which, in his opinion, should either of them be a sufficient 
reason to refuse admission to a patient, no matter how favorable the 
physical signs might be. These were an age of 50 years or over, and 
melancholia. To my mind, a patient between 50 and 60 years of age, 
in the incipient stage of tuberculosis, has just as much chance of get- 
ting well as a younger individual. A state of melancholia is often 
produced by patients being told that they are tuberculous. I have 
known the psychical depression produced by this knowledge to last for 
days, but gradually disappear under the tactful assurance on the part 
of the physician, relatives and friends of the curability of the disease. 
Therefore, I would say that, unless melancholia is of a chronic and pro- 
nounced type, it should not be a hindrance to admission to a state sana- 
torium if all other factors in the patient's condition are favorable. 

My good friend. Dr. Foster, in his admirable paper on " Deten- 
tion Institutions for Ignorant or Vicious Consumptives," suggests that 
a vicious consumptive should be put in jail. Had the doctor visited 
our penal institutions, as I have recently done, where the morbidity 
and mortality from tuberculosis is over 50 per cent, I am quite sure 



AND PREVENTION OF TUBERCULOSIS 4OI 

he would be less enthusiastic about this mode of punishment. If they 
must be confined, then by all means let us have a special institution 
for them and not add any more tuberculous cases than we can help to 
those already existing in the prisons. As attending physician to the 
Riverside sanatorium I have been confronted with the problem of 
vicious consumptives a number of times. Before I relate my experi- 
ence I would like to explain to those who are not familiar with the 
class of patients we receive at Riverside how we recruit them. We 
have a law in New York which authorizes us to remove any consump- 
tive by force to this institution when, in the opinion of the visiting 
sanitary inspector, he constitutes a menace to the health of his fellow- 
men. It has happened a number of times that patients who are taken 
to the institution against their wish violate the rules of the sanatorium, 
particularly in regard to the deposit of their sputum. They thus hoped 
to receive their freedom which was, of course, not granted. Often, with 
tact and patience, we succeeded in convincing the culprit of his wrong 
and he did better; sometimes we punished him by moving him to less 
desirable quarters, and recently my resident physician. Dr. Wm. P. 
Klein, hit upon the excellent idea to place the absolutely wicked in the 
wards of the dying patients. This sort of punishment, severe as it may 
seem, has had up to this time the desired effect. The patient there can 
certainly do less harm than if placed with a healthy prisoner in the cell 
of a jail which offers in itself so many additional factors for the spread 
of tuberculosis, without our placing a vicious consumptive there. 

I most earnestly endorse all that has been said by Dr. Otis, in his 
paper on " The Home Treatment of Tuberculosis," concerning the 
importance of prescribing good food. But I think we should not con- 
tent ourselves in simply prescribing it, but also make sure that our 
patient gets it. How necessary this precaution* is I do not believe I 
can better demonstrate to you than by relating an anecdote from my 
own experience. In my younger days I was attached to a dispensary, 
and among our patients were a goodly number of consumptives. A 
young man, coming to my class, suffered from a moderately advanced 
pulmonary tuberculosis, complained to me of having no appetite.' I 
prescribed for him what I considered a good tonic and advised him to 
improve his appetite by moderate outdoor exercises. A few weeks 
later I saw him again ; the scales revealed an additional loss in weight. 
I asked him whether his appetite had not improved? The reply was 
in the affirmative. He saw the puzzled expression in my face, and 



402 NATIONAL ASSOCIATION FOR THE STUDY 

said : " Doctor, it is not your fault that I did not gain in weight ; you 
improved my appetite, I could eat a whole lot if I only could get the 
food. Being out of employment and having but little money left, I 
have lived on milk and crackers ever since you improved my appetite." 
This might sound humorous, but it is really pathetic, and shows how 
much it is necessary to make sure that the patient really receives the 
prescribed food. 

Dr. C. L. Minor, Asheville: In any discussion of the question 
of sanatoria for tuberculosis, I believe it is most important to consider 
the sort of men who are to be placed in charge of state institutions. 
Ordinarily these positions are given out according to the political in- 
fluence of the applicant and with little or no consideration for his 
especial preparation for this type of work, and often even as to his 
general qualifications as a doctor. All those who have done any work 
in this line realize that the personality of the man in charge of such an 
institution is all-important — his teaching faculty and enthusiasm must 
be of the greatest, and if the ordinary methods of appointment to places 
in the gift of the State are to be followed, the result can only be to 
lessen the success of the institution and therefore to injure the cause 
of State sanatoria before the public. The patients of these State in- 
stitutions should be largely of the worthy laboring class, and even more 
important than the improvement in their physical condition, is their 
being returned to their work so thoroughly instructed and so enthused 
in the cause of hygiene and proper living that they will not only know 
how to conduct their lives rightly in the future and keep themselves 
well, but will serve as centers of instruction to the whole neighborhood 
in which they live. Therefore in any State which is contemplating 
erecting a State sanatorium, the profession should be most careful in 
the choice of its medical superintendent. Young men trained under 
the eye and influence of such a man as Trudeau and filled with his 
ideas would be infinitely better than possibly older and more experi- 
enced general practitioners who yet have had no training in this 
special line. For let it be remembered distinctly that this is eminently 
a specialty and only those who have devoted their time and thought 
to it will make a success of it. 

Turning to another matter, I would note that if State sanatoria 
are to fulfill their functions successfully, it should be carefully seen 
that their inmates come from the worthy laboring class, the loss of 
whose labor to the body politic is a per'^^-'s matter, and whose return 



AND PREVENTION OF TUBERCULOSIS 403 

to working ability as soon as possible is very necessary, not only for 
their own good but for that of the community. If we allow these insti- 
tutions to be filled up by what I would call the slum-dweller, by which 
I mean the hopelessly idle, vicious, worthless and uneducated poor, it 
will be found impossible to do more than improve their physical con- 
dition while they are there and when they are returned to their homes, 
they will only relapse into the filthy habits, unsanitary methods of 
living, and vicious practices which have in the first instance made them 
sick, and thus the money of the State will be thrown away and the 
opportunities for cure and instruction Ci the more worthy poor will 
be lessened. 

I cannot allow to go unnoted the remarks of Dr. Rochester, on 
the harmlessness of drafts. We should be careful while we teach and 
practice the open-air life, to remember not to be carried away into for- 
getting that a localized current of cold air on a susceptible portion of 
the body, such, for instance, as that between the shoulder-blades, can 
be fraught with much harm, and that every intelligent phthisiothera- 
peutist, while he tries to get for his patient the maximum of fresh and 
constantly renewed air, tries also to keep him from the influence of 
•direct draft. 

I was glad to hear Dr. Bowditch speak in favor of properly used 
pulmonary gymnastics, and was sorry to hear Dr. Otis say that he dis- 
approved of them. I have used them, I beHeve, with the greatest of 
benefit in carefully selected cases for years, and increasing experience 
only increases my faith in them. Granted, of course, that the stage 
of great activity of trouble in the lung is past, and that the patient is 
so thoroughly under control as to follow my instructions absolutely, 
then if, as experience teaches me, an improvement of the pulmonary 
condition generally goes hand in hand with aA enlargement of the 
thoracic cavity, and if as very careful tape measures and lead tape 
tracings taken for a number of years, have also convinced me, properly 
used gymnastics favor such an enlargement, then I believe my con- 
clusion that they are of great value cannot be reasonably denied. 

Whether they should be used with the dispensary patients, who 
are not much under the doctor's eye and who are of an unintelligent 
class, may well be open to question, but in the intelligent, eleven years' 
experience satisfies me that they are a therapeutic measure of no mean 
value. 

Mr. E. T. Devine, New York : Not being a clinician or a clima' 



404 NATIONAL ASSOCIATION FOR THE STUDY 

tologist, perhaps I should hesitate to differ from Dr. Minor in regard 
to the character of the average consumptive from the slums or — to 
use the more euphonious term — from the congested districts. Per- 
haps the best rejoinder that can be made to the suggestion that patients 
coming from the most congested and least attractive tenements should 
not be admitted to the sanatorium on account of their character, would 
be to place in contrast with it a declaration made to me recently by a 
large employer that he was opposed to having laborers go to the sana- 
torium because their standard was so raised, and they were given such 
impracticable notions that they were spoiled ever afterwards. 

You will readily see that one view or the other must be wrong. 
If they are susceptible to the uplifting influence of the sanatorium, 
then they should not be excluded because of any general assumption 
of vicious character. In fact, both views appear to me wrong although 
they are mutually destructive. The standards of patients are raised, 
even of those who come from the crowded districts, but the particular 
things which they are taught to value, viz., cleanliness, fresh air, and 
simple, nourishing food are desirable things from any point of view, 
and no employer should object to that being incorporated into the 
standard of living of his employees. 

No doubt there are consumptives of intractable temper and of un- 
manageable disposition. Even these, however, from the point of view 
of the community, are better off in a sanatorium under the immediate 
control of physicians, than in their homes in the tenements under no 
control. In the case of vicious and especially incorrigible patients, the 
discipline of a sanatorium conducted by a health board with police 
powers and with powers of inflicting such punishment as Dr. Knopf 
has indicated, may be essential. 

Dr. Edward O. Otis, Boston: With regard to Dr. Foster's paper 
read this morning with regard to the disposal of the indigent cases I 
must say that I agree with what Mr. Devine has just stated, that not all 
the poor consumptives are of the " slummy " character. They are 
decent working people, many of them, and I do not think we should 
place them in the same class as vicious consumptives. Some believe 
that wards, properly constructed wards, should be built for these people 
in the poor-houses; but I think that these poor, hopeless, advanced 
cases of consumption should be cared for in a properly constructed 
hospital. I see no reason why they should not have as good attention 
and care as the neighbor with the acute form of the disease. In Boston 



AND PREVENTION OF TUBERCULOSIS 405 

we have properly constructed, properly supervised consumptive hos- 
pitals. We cannot persuade these patients to go to the poor-houses 
even if they have the facilities for taking care of them in large num- 
bers; they will not submit to being classed as paupers and lose their 
votes, as is the case in our cities in Massachusetts. Large cities should 
erect and provide consumptive hospitals where these people can be 
properly taken care of and where they can retain their self-respect. 

With regard to the non-enforcement of the spitting laws in Boston, 
we have it everywhere posted that spitting is forbidden, that the penalty 
is $100.00, etc. ; the penalty is far above the amount it should be and 
consequently it is not enforced, nor do I believe it can ever be enforced. 
We should prevent spitting in improper places, but we should provide 
cuspidors. I really think that the solution of this spitting problem lies 
in the provision of cuspidors and in insisting upon people spitting in 
them and nowhere else. 



REPORT OF THE COMMITTEE ON AN EDU- 
CATIONAL LEAFLET FOR DISTRIBUTION 
AMONG THE PEOPLE 

Dr. H. M. Biggs, New York, Chairman 
Dr. William B. Stanton, Philadelphia 
Dr. V. Y. BowDiTCH, Boston 
Dr. Joseph Walsh, Philadelphia 



Names, — Consumption, decline, debility, phthisis, hectic fever are 
some of its general names. Tuberculosis may affect particular parts of 
the body and then be called by special names, as scrofula, hydrocephalus 
or water on the brain, lumbar abscess, iliac abscess, ischio-rectal ab- 
scess, fistula in ano, white swelling, bone caries. Potts' disease or 
hunchback, hip- joint disease and lupus. 

Source of Infection. — Tuberculosis is a communicable disease 
caused by the tubercle bacillus, a minute vegetable organism. It is 
always contracted from another suffering from the disease. 

Colds. — It never comes from a cold, though a cold may develop it 
and first draw attention to it. 

Heredity. — It is not hereditary. It is found very commonly in 
children of consumptives, because they are more exposed to infection. 

Implantation. — The germ or bacillus enters by the nose, m.outh 
or an open wound. Wherever implanted it produces little nodules 
called tubercles. These may grow in size. They may soften, break 
open and be expelled, leaving behind an ulcer or a cavity, bacilli being 
left in the walls of the ulcer to continue the disease. 

Cure. — In cure, nature throws a wall of scar tissue about the 
tubercle or cavity. This wall becomes gradually thicker and thicker, 
growing towards the center, until nothing is left but a scar. 

Relapse. — Until the scar is through and through it may break 
down at any time, leaving the bacilli free to continue their action at 
that place, and a relapse ensues. 

Poisoning. — As the disease develops, the germs manufacture a 

406 



NAT. ASS N FOR STUDY AND PREV. OF TUBERCULOSIS 407 

poison which circulates in the blood, causing fever, increase in pulse 
rate, chills, sweats, stomach disturbances and wasting. 

Contributory Causes. — Though the tubercle bacillus is the sole 
cause of the disease, there are several things which favor its develop- 
ment. The majority of people in good health are not, under ordinary 
conditions, susceptible. Anything tending to lower vitality improves 
the soil for the development of this little vegetable organism. There- 
fore, poor and insufficient food, over-work, alcoholism, worry, dissipa- 
tion, surroundings — like a damp, dark or overcrowded dwelling — se- 
vere diseases — like typhoid fever, repeated colds, etc., — all tend to 
make a person susceptible to the disease. 

Incurable Cases. — When the disease is far advanced and has 
affected the greater part of a vital organ or parts of many organs it is 
incurable. 

Curable Cases. — In earlier stages the majority of cases can be 
cured. 

Mode of Cure. — For the cure the first thing necessary is to build 
the patient up to a perfect state of physical health. This is ac- 
complished by rest, regular life, fresh air and good nourishment. 

Rest. — If the disease is active or advanced, considerable rest, 
even rest in bed, may be necessary. In any case the patient must stop 
work and exercise until the pulse and temperature are under 100. He 
should return to work only on the advice of a physician. The patient 
should always have nine hours' sleep, retiring before ten P. M. 

Fresh Air. — He must sleep alone and, when possible, in a room 
alone. The windows of the sleeping-room should be kept wide open 
day and night, no matter what the weather. The idea is to make every 
inhalation one of unbreathed air. During the day the patient must 
spend as much time as possible out of doors. 

Diet. — The diet should be generous, nourishing and easily digest- 
ible. The most nourishing food we possess is milk, cream, butter, eggs^ 
raw or rare beef and beefsteak. The more the patient consumes of 
these the more quickly he will build up. 

Alcohol. — Alcohol (whisky, brandy, wines and beer) is usually 
harmful. 

Prevention. — In all cases infection of others can be prevented. 
The infectious matter or the germs are contained in the discharge from 
a tuberculous sore ; therefore, in cases of lung tuberculosis, in the spu- 



408 NATIONAL ASSOCIATION FOR THE STUDY 

turn. The germs are very small, and frequently millions of them are 
spit up in a single day. 

Sputum. — If the patient is careful with his sputum he is harm- 
less ; if he is careless he is dangerous to others and also to himself. In 
tuberculosis, spitting is one of Nature's methods of getting rid of the 
germs. The patient should, therefore, never swallow his sputum, for 
fear of infecting other parts of the body. He should wear no beard or 
mustache, to which particles of spit might adhere and be inhaled or 
swallowed. The hands should be washed and the mouth rinsed out 
before eating. 

Spitting. — To protect himself and others he should never spit 
where the sputum may dry and be swept into the air as powdered dust, 
which may be inhaled. He should never spit on the floor, wall, carpet, 
stove or sidewalk. 

Handkerchiefs. — He should not spit into rags or handker- 
chiefs, since he contaminates the hands, face and clothes with them. 

Spit Cups. — The only things a consumptive should use for 
the sputum are spit cups and paper napkins. If the spit cups are made 
of paper they should be burned ; if of china or metal they should contain 
a solution of lye (ordinary household lye), be emptied into the hopper 
once or twice a day and boiled. Pocket sputum cups for use away from 
home may be obtained in drug stores. The lips should be wiped with 
paper napkins. 

Paper Napkins. — When a spit cup is not at hand paper napkins 
should be used for the sputum. These should be used only once and 
put into paper bags and burned. 

Coughing and Sneezing, — When coughing and sneezing, spit 
particles are thrown out, and hence a paper napkin should be held be- 
fore the lips. 

Breath. — The breath of a consumptive does not contain the 
germs and will not produce the disease. 

Soiled Linen. — The patient's soiled wash clothes and bed linen 
should be handled as little as possible and should be boiled before wash- 
ing. 

Disinfecting. — Before a room which has been occupied by a 
consumptive is used again it should be thoroughly cleaned and disin- 
fected or renovated. The furniture, pictures and curtains should be re- 
moved to the yard and scrubbed; carpets should be raised and disin- 
fected; the floor scrubbed and the walls scraped and repapered. 



AND PREVENTION OF TUBERCULOSIS 4O9 

Advertised Cures, — Consumptives are warned against the many 
widely advertised cures, specifics and special methods of treatment of 
consumption. No cure can be expected from any kind of medicine ex- 
cept the regularly accepted treatment which depends upon pure air, an 
out-of-door life and nourishing food. 



DISCUSSION ON THE EDUCATIONAL LEAFLET 
Its Adoption was Moved and Seconded 

Dr. Edward O. Otis, Boston: All leaflets are good, but no one 
leaflet is applicable to all classes and conditions of people. I do not 
think that I have ever seen a leaflet issued by the various Associations 
for the Study and Prevention of Tuberculosis that was applicable to 
all kinds of people. For the working people, though by no means 
ignorant people, there should be printed the simplest possible leaflet 
and the matter should be presented to them in as few words as possible. 
I have here the leaflet gotten up by the Minneapolis people which il- 
lustrates the point I wish to make, say what you have to say in as few 
words as possible and in a direct manner. This leaflet is all right. I do 
not think that we should make so many details in our leaflet and it is 
not at all necessary to mention all the varieties of consumption in the 
printed matter which is to get into the hands of the working people and 
slightly educated persons. What should be impressed upon them Is the 
danger of pulmonary tuberculosis, that they can avoid spreading the 
disease, etc., but it is not necessary to give all the synonyms of the 
disease. It is not at all necessary in the simple leaflet that we desire to 
issue to refer to the different kinds of tuberculosis, but to make simple 
statements regarding pulmonary tuberculosis, because that is the disease 
they need instruction in. There should be some striking headlines, as 
in this Minneapolis leaflet, something to catch the eye of the patient. 
Then it should be stated, too, that if further information was desired, it 
will be given. Excite the people to take an interest in the disease and, 
in that way, lead them to inquire and acquire more information regard- 
ing this dread disease. The matter of curability is not of so much im- 
portance to them as is the instruction regarding the dangers of the 
disease and the methods of prevention ; tell them that it is curable if the 
disease is taken in time. 

Therefore, in conclusion, I shall say that I approve of this leaflet 



4IO NATIONAL ASSOCIATION FOR THE STUDY 

for general distribution, but at the same time I believe that you cannot 
make one form perfect and applicable to all kinds of conditions and all 
kinds of people. 

Dr. De Lancey Rochester, Buffalo: I agree with Dr. Otis in the 
statement that we ought to omit the large amount of material now in 
the leaflet such as the synonyms of the disease. A leaflet designed for 
the instruction of the people should not go out in that form and with 
our endorsement; there is too much knowledge in one way and too 
little in another. I have in mind a patient who went to a general hospital 
in the country with an affection of one knee and the question was as to 
what it was. The conclusion was arrived at that it was a tubercular 
knee, the patient was treated accordingly, and then returned to his home. 
But the people in his neighborhood learned that he had a tubercular 
knee and when he returned to his home on the farm, where he had been 
able to keep two cows upon which depended his source of income, he 
lost all his trade. That is one evidence of the seriousness of giving 
out such leaflets when the people do not appreciate what the different 
forms of tuberculosis are. 

With regard to the curable and incurable cases that too is a serious 
thing in leaflet instruction. I have two cases at the present time with 
both lungs involved and who have gotten well at home, being perfectly 
well and teaching school. Another patient I first saw at the Pan- 
American with a serious involvement of one lung, with cavities in both 
upper and lower lobes. At home in the country, by carefully following 
instructions, she has gotten well. We should not have such cases get 
the idea that there are cases, even the advanced cases with cavities, 
that are absolutely incurable. 

I think too that we should introduce into this leaflet that it is as 
necessary to boil the eating utensils as it is the clothing, etc. That is a 
very important matter. 

Dr. Howard S. Anders, Philadelphia : There is one point that 
seemed to impress me as calling for a few remarks, and that is the great 
number of synonyms for tuberculosis contained in the leaflet. What is 
contained in it appeals to the pathologist and the clinician rather than 
to the intelligent laity. 

I believe another point should be mentioned regarding the nutri- 
tious value of cheese. Mild cheese, to those who like it, is as important 
for their nutrition as cow's milk and meat. 

Dr. Charles L, Minor, Asheville, N. C. : We should divide these 



AND PREVENTION OF TUBERCULOSIS 4II 

educational matters into matters of thought and matters of method, and 

the doctor has combined them to a certain extent in this leaflet. It is 

highly desirable to develop educationally matters of thought. 

There seems to be some doubt as regards the completeness of the 

of the work and, therefore, I move the following amendment to the 

motion : 

RESOLVED : That the leaflet be accepted and that the Committee be re- 
quested to report next year with leaflets calculated for use among the different 
social classes involved in this matter. 

Dr. Joseph Walsh, Philadelphia: As to the amendment I will say 
that most of the charity organizations are calling for leaflets, and 
especially for those that deal with matters pertaining to tuberculosis 
and methods of prevention. Boards of Health in our large cities give 
out special leaflets relating to the prevention of tuberculosis, but what 
the people are looking for is more information that is definite and 
that would have strength such as it would have coming from large 
bodies like this Association. Take, for instance, the pamphlet issued by 
the New York Board of Health in relation to prevention of tuberculosis 
and in relation to the disposal of the sputum ; the more you read it the 
more you are impressed with it. Take too the pamphlets issued by the 
Phipps Institute, and also by Dr. Minor, his " Hints and Helps," as 
well as the Minneapolis pamphlet ; in these you get more than in the 
Board of Health pamphlets. We want to give the information the 
people and the charitable organizations are calling for and I think that 
this leaflet gives such information in a reasonable, concise and clear 
manner, explaining the different things. 

Dr. E. L. Stevens, Des Moines : I want to raise my voice against 
the amendment because the Committee has given this subject such 
careful consideration ; it should not be expected that any one leaflet will 
cover everything. This leaflet is a safe one to follow. I hope the 
amendment will be voted down. 

Dr. De Lancey Rochester, Buffalo : This educational leaflet is for 
the people and it is not intended for Boards of Health ; it is an educa- 
tional leaflet for distribution among the people. 

Dr. H. P. Loomis, New York : I think that Dr. Walsh has struck 
the key-note in his remarks. What goes out from this Association goes 
out with the distinct authority of this Association. I am acquainted 
with this work, having worked under Mr. Devine in New York in the 
Charity Organization Society. We cannot satisfy everybody. This 



412 NAT. ASS N FOR STUDY AND PREV. OF TUBERCULOSIS 

leaflet would not be understood by the ordinary layman. Take this 
leaflet to a carpenter, for instance, and ask him what some of these 
words mean; he may not know what sputum or alcoholism means. I 
think it would be the best course for the Committee to take back this 
leaflet and give us two or three leaflets later, dealing with different 
parts of the subject. 

Dr. Edward O. Otis, Boston : I do not think we are giving all the 
information that is desired in this leaflet, but we should bear in mind 
that there are a number of leaflets issued by various city, state and 
other institutions that can be had for the asking. For instance, the 
prize essay of Dr. Knopf of New York which has probably been used 
by every civilized nation under the sun. I certainly think that before 
giving out anything for general distribution among the people it should 
be carefully considered. When once it has left our hands it is gone 
for good. 

It certainly is not applicable to all kinds of people, and I think the 
Committee should present leaflets to be used by different grades of 
people. I hope that the amendment will be voted for, but I think we 
would make no mistake in waiting for the next report and for a more 
simple leaflet. 

Dr. Charles L. Minor, Asheville, N. C. : I agree that this is a mat- 
ter of the greatest importance and we should use great care in digest- 
ing it in order that we may be able to stand up and say : " That is what 
we back up ! " This pamphlet should be made distinctly a desirable 
one. Much more literature on this subject can be had and it should be 
remembered that any one leaflet cannot cover the ground ; therefore, let 
us wait until next year and then submit a leaflet that we can fall back 
upon. Let us not be in too great a hurry in getting out such a leaflet. 

A vote being taken, the Report of the Committee was adopted. 

Dr. Minor's resolution was also adopted. 



THE AFTER-TREATMENT OF PULMONARY 
TUBERCULOSIS 

By J. A. Wilder, M. D. 
Denver 



The enthusiasm that has been aroused by the extremely creditable 
results obtained by the rational treatment of pulmonary tuberculosis, 
as shown by the statistics of the various sanatoria of this country and 
of Europe, and by the results obtained in private practice by those 
giving especial attention to this subject has reached such a point that 
there appears to be danger among both the members of the medical 
profession and the laity of taking almost too optimistic a view of the 
curability of the disease. 

The chief object of this paper is to emphasize: first, the well 
known tendency toward relapse and chronicity of pulmonary tuber- 
culosis; and second, the length of time necessary for a moderately 
advanced or what is commonly considered an " incipient " tuberculous 
lesion to become thoroughly healed. At present the pendulum appears 
to be swinging too far in the direction opposite to that taken by it some 
twenty or thirty years ago. At that time the disease was generally 
considered incurable, and its victims made a§ comfortable as possible 
until the inevitable termination came. Now we seem to be threatened 
by an error diametrically opposed to this, viz., the tendency to con- 
sider the disease too lightly, and not fully appreciating the severity 
of the disorder, its relapsing character, and the inherent chronicity of 
tuberculous processes in the hmgs as well as in the other tissues. In 
many cases patients do not seek medical advice until the incipient stage 
has passed, their suspicions not having been aroused by the indefinite 
clinical symptoms present during this period. A correct interpretation 
of the earlier physical signs of pulmonary tuberculosis is often difficult 
and seems to be as yet attained by a comparatively small number of 

413 



414 NATIONAL ASSOCIATION FOR THE STUDY 

the physicians in general practice. The tuberculin test, which can in 
many cases be of valuable assistance, is used as an aid to diagnosis by 
a limited number only. As a result the diagnosis is not made in the 
great majority of cases until tubercle bacilli can be demonstrated in 
the sputum, or in other words, before tubercles have generated, ulcer- 
ated, and discharged their necrotic cellular material. The lungs of 
the average patient are therefore the seat of more or less advanced 
tuberculous changes, from the pathological standpoint, before the 
disease is recognized. We must consequently expect to deal with the 
advanced rather than the incipient cases until the beneficent effects 
of such societies as this one have impressed the minds of the members 
of the profession more generally. 

A tuberculous ulcer, no matter in what tissues of the body it be 
situated, is usually sluggish in nature and not infrequently progresses 
in one direction while it is healing in another. The hyperplasia of 
connective tissue in the lung incident to tuberculous ulceration and 
essential to the cure of the disease is a conservative reparative process 
that is necessarily slow. In a lung that is the seat of active tuber- 
culosis the tubercles are almost invariably in different stages of de- 
velopment, so that while some are cicatrizing, others are frequently 
degenerating and ulcerating. It can readily be seen, then, that the 
complete and permanent healing of a tuberculous area in a lung can- 
not, except possibly in the truly incipient cases, be either a simple or 
a rapid process. It is well for us to recall in this connection the words 
of Cornet :^ " Phthisis, even in the early stages, is a severe disease." 
..." No single element in the cure, neither air, nor food, nor 
hydrotherapy, nor medicine, affords any guarantee of success ; it is 
only the satisfaction of all the physiological and hygienic demands of 
the organism, from the greatest to the least significant that can bring 
about this result, and of this fact the physician should not for a moment 
lose sight." Dr. Osler,^ in his address at the Henry Phipps Institute 
on " The Home and the Tuberculosis Problem," states, " Benefit is 
usually a matter of months, complete arrest a matter of years, absolute 
cure a matter of many years." Dr. Trudeau,' in emphasizing the im- 
portance of early diagnosis in tuberculosis, states that at the Adiron- 
dack Cottage Sanatorium during a period of fifteen years, only 11% 

^ Cornet, Tuberculosis and Acute Miliary Tuberculosis, pp. 522-3. 

' Osier, First Annual Rep't Henry Phipps Institute. 

' Trudeau, Trans, of the Association of American Physicians, 1900. 



AND PREVENTION OF TUBERCULOSIS 415 

of advanced cases recovered, in contrast to 68% of truly incipient 
cases that were discharged as apparently cured. 

In giving some of the statistics of this institution, Dr. Lawrason 
Brown^ finds that out of a series of 569 patients admitted as advanced 
cases, and who have been away from it from two to eighteen years, 
28.6% are well and 52% are dead. When we consider the excellent 
conditions under which patients are placed at this institution and that 
a fair, if not even a large percentage of these advanced cases would 
still be considered incipient by many, the figures given make more 
significant the point that it is here desired to bring out. Dr. S. G. 
Bonney,^ in a study of 546 patients who sought climatic changes on 
account of tuberculosis, found that the patients had made an average 
delay of eighteen and one-half months after definite symptoms of the 
disease had appeared before leaving home, giving ample time for the 
formation of advanced lesions, and that in 71% of the cases both lungs 
had become involved. There are individuals, it is true, whose resist- 
ing power to the disease is so great and whose virulence of infection 
is so low that they seem bound to and do recover in spite of unfavor- 
able surroundings and methods of living. To this class belong those 
who recover notwithstanding considerable indoor work, improper 
nourishment, irregular habits and hard physical exercise such as 
horseback riding, mountain climbing, the usual ranch work and 
similar laborious occupations. While some patients do recover under 
these conditions of life, let us recall that they do not do so because of 
these conditions, but in spite of them. 

It is well known, on the other hand, that a certain percentage of 
patients have either such poor resistance, or such virulent infections, 
as demonstrated respectively by the acute pneumonic type and acute 
miliaiy tuberculosis, that even under our nearest approach to ideal 
conditions of life they will eventually succumb to the disease. A large 
percentage of the cases met with in practice, however, belongs to 
neither of these classes. The majority of these patients (unless their 
disease is recognized in its very earliest stages and many even then), 
require a continuous life for some years under the best possible hygienic 
and the most favorable meteorological conditions before we can feel 
assured that their lesions are thoroughly and permanently healed. 
Many patients can undoubtedly be cured through proper methods of 

^ Brown, Jour, of the Amer. Med. Ass'n, Nov. 21, 1903. 
*Bonney, Medical News, Sept. 30, 1899. 



4l6 NATIONAL ASSOCIATION FOR THE STUDY 

living at their own homes, even though cUmatic conditions and mode 
of Hfe there be far from ideal. If they can recover under these con- 
ditions, a larger percentage would recover and those who do recover 
under such conditions would do so in a shorter length of time, if all 
the conditions essential to the cure of the disease were improved; or, 
if any one of them was improved, provided it was not done at the 
expense of other factors of equal importance. The welfare of both 
the patient and the public demands that the person suffering from 
pulmonary tuberculosis should be cured in the shortest possible length 
of time. Until his lesions are thoroughly cicatrized he is in constant 
danger of relapse and extension of his disease, and as long as tubercle 
bacilli are present in the sputum he continues to be to some extent a 
menace to the public, no matter how careful he attempts to be in regard 
to the disposal of his expectoration. 

During a service of one and one-half years at the Adirondack 
Cottage Sanatorium the writer was impressed by the comparatively 
short time required in many cases for the disappearance of consti- 
tutional symptoms, or in other words, the arrest of the phthisis. A 
stay of from only a few weeks to a few months under favorable con- 
ditions was in many cases sufficient to cause fever and night-sweats 
to subside, appetite and digestion to improve, and a considerable gain 
in weight to be acquired. During this period of service my attention 
was also called to another point, this impression having been since 
augmented by a six years' experience in one of the high and dry 
climates, viz., that although such a condition may mean an arrested 
phthisis it does not by any means signify that the tuberculous lesion 
in the lung is healed or has even ceased to progress. It signifies only 
that the system has been enabled to react to the toxins of the tubercle 
bacillus temporarily, and that for the time being the disease, instead 
of being a constitutional disorder or toxemia, i. e., phthisis, has been 
changed to a local tuberculous ulceration, the absorption of toxins 
from which is not sufficient to produce any recognizable constitutional 
disturbance. A patient who has reached this stage, but who, as fre- 
quently happens, still has expectoration containing tubercle bacilli even 
after several years of treatment, although he may be well started on 
the way toward recovery, must be regarded as having the sword of 
Damocles continuously above his head. In these cases it is impossible 
for any one to prophesy when an acute bronchitis, an attack of grippe, 
a lowered resistance of the body from some other disease, or an in- 



AND PREVENTION OF TUBERCULOSIS 417 

discretion in regard to exercise, or method of living, may precipitate 
a relapse that is usually more disastrous in its effects than the original 
attack. A residence of six months or a year in a properly equipped and 
conducted sanatorium or under proper hygienic conditions outside of 
an institution is undoubtedly of great benefit to the patient ; in case 
his disease is not too far advanced, it gives him a good start toward 
getting his lesions healed, and is of great value in teaching him how 
to live afterward so that the healing process may continue. But, six 
months or a year under the above conditions, as has been observed by 
many competent phthisiologists, is altogether too brief a time in which 
to hope for a thorough healing of the tuberculous lesions, except in 
those cases that are incipient in the true sense of the word, and not in 
the sense in which this term is still frequently used. 

Many patients leave their homes and go to more salubrious cli- 
mates who have little or no conception of the seriousness of their 
physical condition, nor the length of time necessary for their recovery. 

Many have the erroneous idea that a stay of a few months or a 
year under favorable climatic and hygienic conditions will result in a 
cure of their illness in the same sense in which this term is used in 
relation to pneumonia, typhoid or other acute diseases, and that it will 
be sufficient to enable them to return to their homes and resume their 
previous occupations and methods of living. Many patients who are 
in fairly good general condition, but who have moderately advanced 
pulmonary lesions are met, who have the idea that they can with safety 
immediately take up work that will confine them indoors a good share 
of the time and will cause them considerable physical and mental exer- 
tion. While it is true that some patients do recover under these con- 
ditions, let us reiterate they do so in spite of them, and it is perhaps 
needless to add that experience has taught uS" the almost uniformly 
unfavorable results of such a life for this class of patients. The major- 
ity of these persons will, unless their minds are early disabused of these 
erroneous impressions, eventually die of tuberculosis. Their lives may 
be prolonged it is true, but their lesions seldom become thoroughly 
healed and they gradually drift on into a chronic ulcerative or fibroid 
tuberculosis or die from an acute exacerbation and dissemination of 
the disease from the old focus of infection. On the other hand the 
number of people whom one meets in some of the high and dry regions 
who have gone there on account of tuberculosis and whose disease 
has become apparently cured is striking and instructive. Some of 



4l8 NATIONAL ASSOCIATION FOR THE STUDY 

them on account of poor digestion and frail physique would hardly be 
expected to recover anywhere. In the majority of these cases one will 
find upon careful inquiry that the patients have had the pluck, per- 
severance and necessary means to stick to the proper rules and regu- 
lations of life to from two to five years, and many of them continue 
to do so in part at least, for years afterward. In an analysis of loo 
cases of pulmonary tuberculosis that have been at least quiescent for 
from one to ten years, the average period of quiescence being three 
years nine months, taken at random from the records of my colleagues, 
Dr. W. H. Bergtold and Dr. C. E. Edson of Denver, and from my own 
records, we find that at the present time eighty-seven are either qui- 
escent or cured and able to work. Twenty-five of the one hundred 
cases have at some time relapsed. Thirteen of these have relapsed and 
recovered, eight have relapsed and died, and four are at present chronic 
invalids. One patient died from cancer of the stomach without relapse 
of his pulmonary trouble. 

Sixty-seven of these cases were originally classified as incipient 
and thirty-three as moderately advanced or advanced. The period 
of quiescence in these one hundred cases before working or returning 
home varies from no time to thirty-six months, the average being eight 
months. 

The eighty-seven cases remaining either quiescent or cured at the 
present time were classified as follows : 

Time quiescent before working (87 cases) : o to 36 

months. Average: 9^ mos. 
Time quiescent before working, 25 advanced cases, at 

present quiescent : o to 36 mos. Average : loYs mos. 
Time quiescent before working, 62 incipient cases, 

remaining well at present: o to 36 mos. Average: 

85^ mos. 



Incipient — 62 or 71% 
Advanced — 25 or 29% 



The twenty-five cases which relapsed were classified as follows : 

Time quiescent before working, 11 incipient cases 

that relapsed : o to 36 mos. Average : 8 mos. 
Time quiescent before relapsing: i to 7 years. Av- 
1^ erage : 2J/2 years. 
Time quiescent before working, 14 advanced cases 
that relapsed : o to 24 mos. Average : lofs mos. 
I Time quiescent before relapsing: i to 7 years. Av- 
[ erage : 3% years. 

The thirteen cases which relapsed and recovered were classified 
as follows: 



Incipient — li - 



Advanced — 14 



AND PREVENTION OF TUBERCULOSIS 



419 



Incipient — 7 - 



Advanced — 6. 



Time quiescent before working, 7 incipient cases that 
relapsed and recovered : to 36 mos. Average : 
nH mos. 

Time quiescent before relapsing: i to 7 years. Av- 
erage : 2f^ years. 

Time quiescent before working, 6 advanced cases that 
relapsed and recovered : o to 24 mos. Average : 
8J/2 mos. 

Time quiescent before relapsing: i to 7 years. Av- 
erage: 4V10 years. 



The twelve cases which relapsed and are at present dead or chronic 
invalids were classified as follows : 

r Time quiescent before working, 4 incipient cases that 
- . . J relapsed and failed : o, o, o, 6 mos. 

ncipien 4 Time quiescent before relapsing: i^ to 3 years. 

Average : 2^ years. 
Time quiescent before working, 8 advanced cases that 
relapsed and failed: 8 to 18 mos. Average: I2j^ 

Advanced — 8 •< mos. 

Time quiescent before relapsing: i to 4}^ years. 
1 Average : 2 years. 



Of the eighty-seven cases quiescent or cured at present, fifty-three 
or 61% have continued to live in the climate in which they recovered, 
or in a similar climate and thirty-four or 39% are living at their 
former homes after having lived in Colorado an average time of 9^4 
months after their lesions became quiescent. 

Of the twelve cases that died or are chronic invalids after having 
been quiescent from i to 4^ years, the average being 2^ years, eight 
continued to live in the climate in which their lesions became quiescent. 
Four returned to their homes after having lived in Colorado an average 
time of eleven months after their lesions became quiescent. 

The proper advice and management after the patient's lesions 
have become quiescent, after his constitutional symptoms have disap- 
peared, after he has been well started on his way to recovery, appear 
to be the points in the treatment of the disease on which there seems to 
be danger of laying too little stress. In the majority of cases it is only 
this continuation of the out-of-door life, proper nourishment and con- 
servation of energy that eventually leads to the goal for which we are 
working, i. e., the cure of the disease, and its value for the future wel- 
fare of the tuberculous patient can hardly be overestimated. 

Many patients are unable to take advantage of our advice in re- 
gard to this point, on account of having insufficient means; but we 



420 NAT. ASS N FOR STUDY AND PREV. OF TUBERCULOSIS 

all meet patients quite frequently who are hopelessly ill whose lives 
we feel confident might have been materially prolonged if they had 
fully appreciated the necessity of carrying out the details of treatment 
for a period of years, rather than months. 

Although so-called quiescent lesions are of course greatly to be 
desired, our efforts should not relax when this stage is reached, and 
we should not lose sight of the fact that this means only an arrested 
phthisis, which is but the first step in the cure of a disease which, on 
account of the nature and severity of its pathological lesions, is 
essentially of long duration. 

These points should, in my opinion, be fully explained and abun- 
dantly emphasized to patients by their physicians and those patients who 
are obliged to leave home, if they improve in a satisfactory manner in 
the locality to which they go, should if possible reside there per- 
manently, not forgetting, however, that unless their conditions of living 
continue in a great degree similar to those that were necessary for 
the arrest of their disease, relapses and extension of the disease are 
prone to occur even in those localities best adapted to its cure. 

In summarizing, I beg to mention once more the following points : 

1. The supreme importance of early diagnosis, and of proper 
medical advice when the disease is still incipient. 

2. The great tendency toward relapse and chronicity of the 
disease. 

3. That although quiescent lesions and temporary arrest may 
often be obtained in a short time, permanent arrest and cure usually 
require a period of years, even under the best possible conditions of 
living. 

4. That patients should be instructed not only for their present, 
but for their future welfare